Identifying the early warning signs

and talking at an early stage



Presenteeism

Presenteeism is a term used to describe someone at work who is not working to their full capacity because of ill health. Some employees turn up for work even though they feel mentally unwell because they fear the possible stigma and discrimination from colleagues and managers if they disclose their condition. This can have a number of negative impacts both on the person and on the organisation.

Ideally, if an employee is experiencing a mental health problem at work then they should feel able to raise this with you, their manager. Some employees feel unable to do this because of the perceived stigma and discrimination they feel they may face or for a number of other reasons.

Sometimes employees may not realise they are becoming or are already unwell. You are not expected to diagnose their condition but as their manager, the earlier you notice that an employee is experiencing mental health difficulties the quicker you can take steps to help them. The longer you leave a situation like this the harder it is to solve the problem and indeed the employees’ condition may get worse.

Identifying early signs of distress

Some of the key things to look out for are changes in an employee’s usual behaviour, e.g. poor performance, tiredness or increased sickness absence. You might notice an increased use of alcohol, drugs or smoking. A normally punctual employee might start turning up late or experience problems with colleagues. Conversely, an employee may begin coming in much earlier and working later.

Other signs might be tearfulness, headaches, loss of humour and changes in emotional mood. As a manager you should be aware of the wider organisation’s impact on employees. It might be the case that certain tasks, work environments, times of the day or particular teams are more likely to be associated with employees experiencing difficulties.

"It's important that managers have a holistic view of their staff."

"I feel the welfare of my staff is very much my concern. I'm assiduous about being aware of pressures they are facing in their working and home lives."

Marjorie Thompson, Marketing Consultant

Usually the key is a ‘change’ in typical behaviour. Your responsibility then as line manager is to know your staff.

Using ordinary management procedures to identify problems and needs

Regular work planning sessions, appraisals or informal chats about progress are all ordinary management processes which provide neutral and non-stigmatising opportunities to talk about any problems an employee may be having.

You might find it helpful to use open questions that allow the employee maximum opportunity to express concerns in his or her own way. For example:
“How are you doing at the moment?”
“Is there anything we can do to help?”
If you listen and are empathetic, an employee will feel more able to open up and be honest with you thus making it easier for you to then offer the support that is needed.

If you have specific grounds for concern - such as impaired performance, it is important to talk about these at an early stage. Ask questions in an open, exploratory and non-judgmental way. For example,
“I’ve noticed that you’ve been arriving late recently and wondered if there was a problem.”
When talking to an employee there are three useful points to remember;
  • don’t assume work pressures affect everyone in the same way.
  • make adjustments if a person is not coping, and
  • ‘chats’ should be positive and supportive – exploring the issues and how you can help.

Understanding patterns of absence

If someone is having frequent short bursts of sickness absence with a variety of reasons such as stress, migraines, and back pain or there is no reason given, there may be an underlying, mental health condition that should be discussed.

If you are to look systematically at patterns of absence, staff need to be able to trust you. They need to be reassured that your motive is to improve healthy working, not to castigate. After reviewing absences you may therefore need to communicate with staff what changes are being made to improve peoples’ health and well-being at work.

Things to consider when an employee appears or says that they are ‘stressed’

Using the term ‘stress’ is not always helpful as people use it to mean different things. A distinction therefore needs to be made between ‘pressure’, ‘stress’ and ‘mental health conditions’. We all feel under pressure some of the time but not everybody suffers the adverse reaction of stress or a mental health condition. We all react differently - one person’s spur to action is another’s nightmare and may mean they become less effective at work.

A person’s ability to work under pressure may vary depending on what’s happening outside work. Remember that, in law, it is your duty to ensure that your employees are not made ill by their work. Failure to assess the risk of stress and mental health conditions and to take steps to alleviate them could leave you open to costly compensation claims.

There is now considerable case law in this area. Fortunately, in most cases, adjustments can be made easily and inexpensively and most adjustments are about good management practice that will help others. For more information about assessing the risks or good management practice on work-related stress see HSE’s website.

Talking at an early stage

Engaging with someone who is reluctant to talk about their mental health

Firstly, you need to reassure the employee that your talk is confidential, although in certain situations you may not be able to guarantee total confidentiality (see below). Then you should consider - from the employee’s point of view why he or she might be reluctant to talk. Are they fearful about being judged or even of losing their job? Is it really safe for them to be open with you? Will any disclosures be treated sympathetically and positively? If this employee has seen others with similar problems being discriminated against then from their point of view they are wise to be cautious.

You need to be realistic. You may not be able to change the culture of the organisation overnight but you may be able to take some first steps.

In the short term you can meet the person in a private confidential setting. You could even meet outside the office, in a cafe or somewhere the employee feels comfortable. If it is too difficult for the employee to talk now reassure them that your door is always open.

Before the meeting ask if the employee wants to bring an advocate, trusted colleague, friend or family member to support them in a meeting. Indeed some people might find it easier to talk to someone of their own choosing, e.g. someone of the same age, gender or ethnicity - or someone who is not their line manager.

In larger organisations the occupational health advisors may liaise with staff. In cases where employees are reticent about contacting the occupational health department you might choose to intervene. Whichever approach is adopted clear communication between you
as line manager and the occupational health department is needed to ensure that contact with the member of staff is co-ordinated and supportive.

You must be clear about confidentiality and who will be told what. You can clearly explain the limits of your confidentiality (personal information is confidential but issues that may have a health and safety risk to the employee or colleagues will need to be discussed further).

You should agree with the employee how problems will be monitored. If adjustments are being made, ask how they wish this to be communicated to other staff.

Make sure you deal with any hurtful gossip or bullying promptly and effectively. It is your responsibility under the Disability Discrimination Act to ensure that employees are not bullied or harassed on account of a disability.

Managing an employee who becomes tearful and upset

Try and be calm yourself.

Emotions are a natural part of life and sooner or later it is extremely likely that a member of your staff will become upset. This can happen for any number of reasons and can be connected to something at work or outside of work. When this situation arises;
  • reassure them that it is OK to be upset and that you are listening. In fact, the process of listening may provide an important space for both you and the employee to gain insight into the problem and possible actions
  • ask if there is anyone they would like contacted or if they would like to choose someone to be with them
  • make sure the employee is offered and provided an appropriate space where they can express emotion freely and compose themselves in privacy
  • alternatively, you might suggest that you both leave the building for a short time to go and have a coffee or for a short walk to give the person time to collect themselves. They may wish to go alone. However, it would be best not to let the person leave the building alone if they are still very distressed. They may also nominate someone else to go with them
  • be respectful towards what the employee would like to do. Once they have recovered sufficiently, they may want to carry on working or take a break or possibly go home
  • reassure the employee that they are valued and that you support them, as they may feel embarrassed about what has happened, and
  • never just ignore the person even if you are worried how they will take your intervention, doing nothing may make the situation worse.

Try to be sensitive to the level of information and support the employee can cope with at a given time. In the midst of a crisis they may not be able to think clearly and take on board information. The important points are to talk to them, reassure them their job is safe, state positively that all help, assistance and support will be offered, and affirm that discussion will continue at a pace that suits them.

Problems can build up over time and whilst you may feel the pressure to take action immediately, it may be better to take some time to calm yourself, reflect and consider the options. Try to distinguish, with the person, between what is urgent and what is important.

You may also need support in managing this kind of situation but do take into account the confidentiality of the employee. If the session is not proving helpful for the employee you could then rearrange for another time in the near future to discuss the issues when the person is less upset.

Managing your own mental health

There may be times when you experience distress yourself. It is important to look after your own mental health. Finding support whether it is internally within the organisation or externally with friends and family for example, can be extremely helpful towards re- establishing well-being.

Managing the rest of the team

Be aware of the impact one employee’s mental health conditions could potentially have on the rest of the team. This could be in response to;
  • the person’s particular symptoms or behaviour while unwell
  • any reasonable adjustments that are made, and
  • an increased workload for staff if the person is not well enough to work.

In these instances it would be advisable to;
  • be honest and open with the team as long as it does not breach any agreed confidentiality with the employee concerned
  • identify working conditions that may negatively influence the well-being of the team, and change them where necessary
  • create an environment where staff can air their concerns openly to avoid gossiping and any resentment towards the member of staff who is off work due to mental health conditions, and
  • treat all staff fairly otherwise staff may show lower commitment to their job. If a member of staff with a mental health condition is offered flexible working hours as a reasonable adjustment for example, then it maybe appropriate to offer the same conditions to all staff. Staff do not have to have a mental health condition for you to create flexible arrangements. The important thing is to focus on promoting the well-being of your team. Employees who feel stable and supported will help improve performance and retention of staff through increased employee contentment and loyalty.

Communicating with colleagues

You should agree with the employee whether and precisely what they wish colleagues to be told. In general it is best to talk to someone experiencing mental health conditions in an honest, matter-of-fact way - that is in the same way you would deal with someone’s physical health problems.

If the person takes sick leave you could send them a card as you would if they were off work with a physical problem. You should ask whether they want to be visited and respect their wishes.

The person’s requests may change very quickly or over time. If they initially request little contact, this may change as their mental health improves. As far as possible, someone with a mental health condition should be treated in exactly the same way as any other sickness absence.

If your organisation has a written absence policy, you will be in a position to discuss with the person at the start of absence how often contact should be made. The employee then has a right to expect that frequency of contact.

Recognising when professional/clinical help is needed

Although someone does not have to be 100% well to work and in general work is good for mental health, in some instances an employee may really not be mentally well enough to work. If someone continues to show signs of distress despite the reasonable adjustments and support you have provided then you should seek advice from human resources (HR) and/or refer the individual to the occupational health (OH) department. Sometimes people refuse to be referred for an OH assessment and in these instances you can tell them that you want them to see their GP before coming back into work.

If you work for an organisation without an OH or HR department you can encourage people to see their own GP and seek appropriate help. You can state what their job involves in a referral letter.
One in four people will experience ‘mild to moderate’ mental health conditions, such as anxiety and depression. However, a much smaller percentage will experience episodes of more severe anxiety or depression that may be associated with episodes of ‘mania’. Mania may present as:
  • extreme heightened activity, and/or
  • loss of touch with reality, hallucinations, and distortion of the senses e.g. seeing or smelling things that aren’t there.

In these rare instances, an employee may behave in ways that impact on colleagues or clients. In this situation you need to be aware of your responsibilities for all employees.

Try to take the person to a quiet place and speak to them calmly. Refer to the ‘advance statement’ (explained below) if one has been written. Suggest that you contact
a friend or relative or that they go home and contact their GP or a member of the mental health team if appropriate.

You might also be able to help them to make an appointment and even go with them to the surgery – if they so wish.

Be aware that if someone is experiencing hallucinations or mania, they may not be able to take in what you are saying. In this case the person will need immediate medical help.

If an employee is disturbing others and refuses to accept help, you should seek advice from your occupational health provider if you have one, or from the person’s GP if you know whom that is otherwise contact NHS Direct, or the ambulance service if the problem is urgent.

This situation is rare and when it does happen it is usually not completely ‘out of the blue’. This is why early identification of changes in behaviour and prompt action are so important.

Advance Statements

Some people find it useful to draw up an ‘advance statement’ which explains how they wish to be treated if they become unwell at work. The statement can include information on signs that indicate that the person is becoming unwell, who should be contacted or provided with information (perhaps a close relative, care coordinator or GP), what sort of support is helpful and what is not, practical arrangements as well as treatment preferences.

If an employee draws up an advance statement in agreement with you, it is important that you put the statement into practice as agreed, if and when the employee becomes unwell.

Some organisations make it mandatory for all staff to prepare an advance statement to reflect the fact that, a) anyone can develop a mental health condition, b) an inclusive process increases the likelihood of people completing such a form, and c) it makes people consider their mental health and the mental health of others.

Download an Advance Statement template (RTF document, compatible with Microsoft Word and other word processors)

Additional support for an employee who is distressed or develops a common mental health condition at work

Company-funded counselling schemes and free NHS services can provide a safe space for staff to explore emerging problems before they become acute.

The National Institute for Health and Clinical Excellence (NICE) evidence based guidance shows that psychological therapies can help people overcome depression and/or anxiety.

People with these conditions are also being offered more talking treatments, through significant Government investment in the Improving Access to Psychological Therapies (IAPT) programme. The programme focuses on cognitive behavioural therapy (CBT) but it will be extending to the other NICE-compliant treatments as the programme is expanded.

Employment advisors will also be part of the IAPT programme and will work alongside therapists, providing information, advice, and guidance support to help working people remain, gain or return to work. For more information go to www.iapt.nhs.uk

Next page: Issues to raise with an employee who is distressed