Mental disorders result in massive amounts of lost productivity each year. While many employers are developing policies to support a healthy workforce, there is no shared vision for mental health in the workplace. In South Africa, the challenge extends to the mental impact of socio-economic legacy issues such as gender, race and social inequalities. This article examines the extent of the problem and some interventions to resolve it.
The statistics appear to be telling the story – although even these may be grossly under-reported. The World Health Organization estimates that by 2030 depression will become our most burdensome illness, more than cancer, diabetes and chronic respiratory diseases combined.1 The World Economic Forum estimates that mental disorders result in lost productivity of $1 trillion each year.2 Statistics from the World Federation for Mental Health show that an average of 36 work days are lost for each episode and more than 10% of working people have taken time off for depression.3 But as far as South Africa is concerned (Life Esidimeni aside), we really don’t have useful statistics on the cost of not managing our mental health more effectively.
For example, our own experience in Alexander Forbes Health Management Solutions suggests that 35% of all temporary-incapacity leave applications from our sample of corporate clients are due to mental and behavioural issues. Or we can look at the experience of a few of our larger clients and report that out of the extended sick leave applications received, 25% were due to mental and behavioural disorders, and the average time off requested was 18 days. While this data suggests these trends have been increasing over the last five years, it’s hard to know why: better record-keeping, a greater acceptance of ‘emotional problems’ as a viable excuse for absenteeism, or a genuine decline in the mental well-being of South Africans are all potential reasons.4
Even if someone is assessed as being relatively mentally healthy, minor day-to-day fluctuations might be at the heart of what accounts for much of the presenteeism we see in the workplace.
Consider the distracted employee who, for a few frantic, hopeful weeks, spends more time in the office on a dating app than working on the minutes of a board meeting. Certainly no one at this point is keeping track of this slippage in productivity, but it’s real – and there are ways that corporates can be more supportive in helping employees manage these temporary emotional overloads. The blocks in Figure 3.4.1 present, as best as we can guess, what some of the statistics look like for South Africa.
Several things have made it difficult for companies to get a clear handle on the mental well-being of their employees.
Definitions here matter – but they can become conflated. Mental health The World Health Organization (WHO) defines mental health as a state of well-being in which every individual:
UK-based charity MIND states that mental well-being refers to how well you can operate day to day with or without the presence of a mental illness. The criteria it uses to define good mental well-being are an ability to:
The WHO defines this as the response people may have when presented with demands and pressures that are not matched to their abilities. This leads to an inability to cope, especially when employees feel they have little support from supervisors or little control over work processes.8
A mental disorder refers to a range of conditions that ‘affect mood, thinking and behaviour and interrupt functioning such that an individual can no longer cope with the normal stresses of life, love, play, work productively and make a contribution to community’.9
When employers consider how to approach the question of employee mental well-being, they tend to do so in the context of absenteeism or medical aid claims. The definitions with the greatest relevance here are:
Acute mental illness: characterised by significant and distressing symptoms of a mental illness and requiring immediate treatment. This may be the person’s first experience of mental illness, or a repeat episode or the worsening of symptoms of an often continuing mental illness.
Chronic mental illness: a condition or disease that is persistent or otherwise long-lasting in its effects, or a disease that comes with time. The term ‘chronic’ is often applied when the course of the disease lasts for more than three months.10 Just how useful are these definitions? More importantly, how accurate is our data in relation to them?
Under-reporting is often a function of both the stigma attached to mental health issues and the fact that there’s little understanding in the workplace of what constitutes a mental health issue. As a result, reporting on these issues in the workplace is much lower than on other health conditions. It’s quite likely that a mental health issue is simply categorised as another health issue.
Under-reporting also exacerbates our ability to estimate the cost to the employer of not dealing with mental well-being. The issue around under-reporting is not only the stigma attached to mental illness but also how a company monitors the use of sick leave and applying for leave once sick leave has been taken. Many companies do not have systems in place to record sick leave accurately or get managers to check if it has been reported. In addition, the law states that doctors do not have to disclose the medical condition on a ‘sick note’, so there’s no indication of whether the leave is a result of mental illness. Employees also do not have to submit a sick note for taking just a couple of days’ sick leave. All these factors lead to under-reporting.
Allan Sweidan, CEO of the Akeso Clinic Group, makes this point:
[…] the real conundrum is that, while every healthcare system is looking for the highest quality of care at the lowest cost, with psychiatry we are dealing with a more complex dynamic. Nobody has yet comprehensively defined what outcomes should determine quality, and no system has yet defined what costs should be incurred in the achievement of desired outcomes.11
Unlike other, more easily measurable, areas of medicine, psychiatry still has a long way to go.
But while we may have an inaccurate notion of the actual cost of mental health problems in the workplace, studies in the UK and US suggest that the split in costs to the employer works out to something in the order of:
These studies suggest that workplace interventions or proactive measures could save companies up to 30% of these costs. But uncertainty about the true nature of the costs has the knock-on effect of limiting our ability to measure the impact of workplace interventions by employers.
What we do know is that these studies don’t calculate the personal costs to families in the form of family breakdowns, loss of income or debt. Add these into the equation and the picture could be considerably more concerning.
4. Finally, we don’t really have a clear picture of the cost of mental health issues to the state and society at large. What we do know is that people with mental health problems use significantly more unplanned hospital care for physical health needs than the general population. A UK study, for example, showed a 3.6-times higher rate of potentially avoidable emergency admissions.13
Some factors to consider to ascertain the full breadth of that cost would be:
Discovery Health has been helpful in providing these statistics:14
It’s often hard to know exactly where someone is on the continuum at any point in time. We can see evidence of behavioural change, but at what point do these tiny ‘unravellings’ suggest that something more serious is brewing? Consider Table 3.4.1. We may be able to pick up one or two warning signs but connecting the dots to get a full measure of the problem may well be beyond the skill set of a colleague or manager.
More problematic is that most colleagues may well feel this is not their business or responsibility.
Perhaps of greatest concern is, at best, that the mental health policy for South Africa is unclear. In summary, the challenge employees face with mental health issues in the workplace is that South African employers simply do not see it as a priority – or at least one that warrants proactive measures. Most employers believe their employee assistance programmes (EAPs) and whatever assistance employees might get through their medical aid schemes will provide whatever support is needed.
If the employer gets involved at all, it’s generally because some workplace incident has demanded a company-wide response. This is not meant to be a harsh criticism of employers. In reality, there’s very little insight into what would be best practice. And for companies that do try to seek assistance, there is little to go on to determine how well such an investment would pay off.
Deloitte’s UK study on workplace mental health sums up the problem best when it says that our efforts to provide effective support for employees are a function of:18
We believe that, collectively, we can do better. This is what our next segment sets out to address.
We start here with a plea directly from the 2017 report of the World Federation for Mental Health (WFMH):19
One in four adults will experience mental health difficulties, yet prejudice and discrimination are significant barriers that deprive people of their dignity. To make dignity in mental health a reality requires every member of society to work together. It requires action in the community and, importantly, in the workplace.
One in five people in the workplace experience a mental health condition, and while many employers are developing policies to support a healthy workforce, there is no shared vision for mental health in the workplace.
How, then, could we move towards that shared vision? What follows is an aggregation of the best thinking we believe has emerged from the experiences of professionals and advocacy groups globally (a list of the resources we used is given on below).
What we see is that to get this right, we each need to play a part: employers, HR departments, managers, colleagues and family members.
How do we start creating a workplace that puts a priority on emotional and mental well-being?
To begin with, we need to start giving emotional and mental health the same priority as physical health. This means putting pressure on our medical aid providers, our EAP providers and our insurers to look at providing more comprehensive resourcing.
We need to actually communicate to employees that this a priority. This means that we need to:
We need to demonstrate that we listen. We care. It is up to us as employers to start the conversation. Mercer Marsh provides an excellent way of illustrating how that communication could work (see Figure 3.4.5).
Here are some considerations for making this work:
This insight allows us to move to the next part of our discussion on emotional and mental health. We have spoken about employers saying they value the emotional, social and mental health of their employees – but the real measure of that comes when we can marry employer values to employee values. Dysfunctional workplaces are often a result of a disconnect between those two elements.
Mercer Marsh Benefits in Asia has produced some particularly interesting work on what they term ‘turning proactivity on mental health to productivity’. We’ve used some of their work to show how we could embark on a similar campaign for South Africa.
We start by taking a leaf out of Benefits Barometer 2017: Changing world of work. How can we marry the use of data analytics and corporate strategic planning to get to a better, integrated solution?
For a South African variation of this approach we have added a fourth dimension: what needs to take place in the workplace to address broader societal needs around inequality, diversity and transformation. The fine points of these discussions are fleshed out in the next few chapters. Still, the process works very much the same: identify what your company values, identify what your employees value and identify what your broader society values.
When we complete those assessments, we will be on our way to cementing the link between well-being for the individual, well-being for the workplace and well-being for South Africa.
I have been one of the lucky ones. When my husband died suddenly on an overseas business trip, I too was on a business trip – but on another continent. The first shoulder I grieved on belonged to a colleague I barely knew. I was fussed over and comforted in the most touching way imaginable, packed up and bundled into a car by a bevy of caring companions who ferried me to the airport in convoy. How the flight home to Johannesburg was paid for is still a mystery. And when I arrived back, I was embraced by two people whom I’d only known on a purely formal basis – none other than my Chairman and CEO. Both almost two metres tall, they loomed over me like a giant protective shield.
I was a stranger in a strange land. My children and I had no family here. In that moment, the company would become my family.
I had been with my company for only six months, so the extended hands came as a surprise. At that point, the unravelling of my life was only just beginning. I would need those extended hands for much, much longer.
With my husband’s death came an avalanche of collateral losses – of every financial and emotional support base we had previously known.
And still I remained shielded from the full force of the emotional, psychological and financial blows. Personal bankruptcy was staved off by an unexpected bonus. It might have been bonus season – but how did I possibly deserve a bonus after only such a short time? Colleagues stepped forward to cover the kids’ university fees when I desperately needed to keep their lives intact and on track. In the three days that I had to get out of our family home, small armies of assistance arrived to help me reduce 18 years of a very rich life, and all its collateral chaos, into a one-bedroom lock-up-and-go apartment.
One asset remained: a 10-year-old Discovery 4x4. But that, too, met a terrible end when, in a frenzied rush to meet the lawyers, I crashed it into a pillar in the basement of Alexander Forbes. The company had every right to refuse the insurance claim. I was driving without a licence. That had been snatched from me (along with my passport, bank cards and handbag) in a late-night smash-and-grab on the way back from picking up my husband’s ashes from OR Tambo International.
But they didn’t refuse: the company paid in full.
Months later and the end seemed nowhere in sight. This was when the magic happened. My teammates took over. They did all the heavy lifting. Keep Anne afloat. Keep Anne sane. When I couldn’t bring myself to go home to an empty flat, they would stay on – and talk. And talk and talk, and include me in all sorts of ridiculous diversions, mindless escapades and 24/7 WhatsApp messaging (clearly a pretext to make sure I hadn’t checked myself out). I needed to belong to something. They understood that. And now I belonged to this wonderful bunch of misfits. It was life-affirming.
No one flinched when I would unexpectedly burst into tears in the middle of a meeting or at an office party. When I flew off the handle at a colleague or situation for no apparent reason, both my bosses and my colleagues would come forward with support, not reprimands. People just seemed to know when to give me space to grieve and when to hold me tight to keep me from losing my mind.
That grieving process took seven years. Amazing, that. It’s even hard to type that sentence out. But that is the nature of grief. It doesn’t conform to any corporate policy. It doesn’t recognise the unfathomable three-day leave statute – the one that applies only to immediate family members (whatever that means).
This suggests four important things:
I said that I counted myself one of the lucky ones. I can see that today. I work with a lot of amazing women in this company. What strikes me is how much of the burden of death and family pain falls on their shoulders. Each day, I see extraordinary scenes unfold where the death of a close relative will suddenly throw a woman into the role of mother to a child she may barely know – and with that comes all the legal and emotional baggage of sorting out that traumatised child’s life. I’ve watched women take on the heart-breaking role of nursing a dying child when they know there’s no medical salvation ahead. I’ve seen women become embroiled in senseless and endless legal battles when a spouse is mentally ill, or divorced parents both die in the middle of an incredibly complex settlement dispute without any wills. I’ve seen women stealing away from work to try to track down missing children or relatives when their plight seems almost hopeless.
But all these women I know and watch and care for have one thing in common: they hold down incredibly important jobs at my company, with almost increasing demands and a largely unknowing manager wondering why they aren’t ‘delivering’.
This isn’t a story about an uncaring company. We’ve already seen that it can be caring. It’s a story about what happens if a company doesn’t send out clear signals that it understands how incredibly complicated life can become, and how ready and willing it is to send out lifelines if they are needed.
It’s what happens when an employee doesn’t realise that it’s okay to reach out for help or to ask for a bit of slack.
Most employees know their legal rights: we are all entitled, as employees in South Africa, to three days of ‘family responsibility leave’. Some companies, like ours, extend that to five days. But there is no way that any of the scenarios I described above could be resolved in the space of three or even five days. In my case, things could not completely settle for years.
The problem is, what happens after that leave time is exhausted becomes murky. Invariably, it’s ‘decision-making on a case-by-case basis’. More often than not, those decisions rest with line managers, not necessarily HR. In some cases, line managers will opt for flexibility and lifelines in spite of HR policies.
I’m just not sure that’s good enough. I know that we could have done so much more as a company for those women I’ve mentioned. But either they didn’t share or we didn’t think through how we could help. Sometimes – perhaps most of the time – when we are dealing with the death or the disturbance of a loved one, we need more than ‘a little help from our friends’.
I’ve added this ‘postcard from the edge’ to our section on mental health because the principles we are working with are not dissimilar. There is probably no real way to establish a rule set here, given the extraordinary breadth of tragedies employees can be confronted with. Last year I took heart when I saw that Canada was proposing leave policies for employees who needed long-term leave allowances to care for a sick relative or track down a missing child (that last one surprised me – until I saw its usefulness for South Africa). Perhaps it’s one answer – but it can’t be the only answer.
What all this comes down to is the kind of culture a company chooses to project. A culture that knows it needs to go beyond talking the talk. A culture where people know it’s safe to tell their stories, share their pain and, mostly, share their burden. This kind of support stretches the reach of even the best employee assistance programme. It needs to be embedded deep in the DNA of the company.
Making the choice to have ‘that kind of culture’ can be surprisingly inexpensive – especially when colleagues are there to pitch in. It’s simple: when tragedy strikes, every employee should be able to access a single support person who can consider where and how the company could best support them. It doesn’t need to be HR or the line manager. But it does need to be someone who steps forward and says, ‘I will make sure that lifeline is available until you know you’re okay. I will make sure I understand enough of your needs to point you to the right resources.’
Appreciate that as an employer you can play an invaluable role simply because you have significantly better leverage, or buying power or access to professional services than any one employee. Use those advantages to good purpose. Think creatively.
I know what it feels like to be saved from falling just when you think falling is the only option. I also know that it took a company to make that all work – not just an individual. I won’t easily forget.
1, 2, 3 World Federation for Mental Health (WFMH). 2017. Mental Health in the Workplace (online).
4 Sachs, M. 2017. Mental Health in the Workplace, Health Management Solutions, Alexander Forbes (online).
5 Independent Online (IOL). 2017. Mental health a serious issue in South Africa, Independent Online, 21 July 2017 (online).
6 World Health Organization (WHO). 2014. Fact files: Mental health: a state of well-being, updated August 2014 (online).
7 Deloitte Centre for Health Solutions. 2017. At a Tipping Point? Workplace Mental Health and Well-being, March 2017 (online).
8 World Health Organization (WHO). 2018. Occupational health: stress at the workplace – some simple questions and answers, 5 July 2018 (online).
9 IOL (2017).
10 Government of Malta health website, hospital services page (www. health.gov.mt), 26 July 2018.
11 IOL (2017).
12, 13: Deloitte Centre for Health Solutions (2017).
14 Ismail, A. 2017. REVEALED: The mental illnesses costing SA billions, News24, 26 July 2017 (online).
15 Ismael (2017).
16 WFMH (2017).
17 Mercer Marsh Benefits. Turning Proactivity on Mental Health into Productivity, Asia Employee Health & Benefits.
18 Deloitte Centre for Health Solutions (2017).
19 WFMH (2017).
20 Deloitte Centre for Health Solutions (2017).