Training for line managers should focus on primary prevention of mental ill-health at work

This article focuses on the mental health of working-age adults who are not being treated by statutory mental health services. It proposes preventive approaches to mental ill-health through line manager training and support.

Work-related mental ill-health is a significant public health concern, which has been exacerbated by the Covid-19 pandemic. The UK Labour Force Survey identified 914,000 workers suffering from work-related stress, depression, or anxiety resulting in 17 million working days lost, an average of 18.6 days per case. ¹ This accounts for more than half of all work-related ill-health cases and working days lost due to ‘ill-health’ (51% and 55%, respectively), ¹ with a significant economic impact. ²

While acknowledging the talents and strengths of multitudes of managers across sectors, a lack of managerial support is one of the leading causes of common mental health problems in a workplace context. ¹ Although line managers significantly influence employees’ mental health outcomes across various work contexts,^3,4 support offered is highly variable and managing employees with mental health concerns can be perceived by their supervisors as a source of stress. ⁵ It is well-established that managers play a vital role in managing psychosocial risks in the workplace, ⁶ but some may lack the necessary resources or support within their organisation to enact this. At an individual level, they may lack the knowledge or skills to ensure jobs are designed and managed to prevent work-related stress, supervise an employee with mental ill-health or navigate the complexities of return-to-work to support those who have been absent. Furthermore, mental health stigma continues to exist in the work context. ⁷ Managers’ behaviours towards employees with mental health issues are related to their own attitudes towards mental illness and their confidence in discussing mental health. ⁸ These are modifiable factors that could be targeted through line manager training. However, workplace interventions targeting managers are limited and tend to be based on secondary- and tertiary-level intervention. Secondary-level interventions are all about detection and management of stress and mental health problems by increasing employees’ awareness, knowledge, skills, and coping resources. Tertiary-level interventions involve minimising the effects of poor mental health at work once they have occurred through the treatment of symptoms and provision of remedial support.

In a national survey, only 8% of UK managers reported they had received training to support return-to-work. ⁹ This is being addressed in the UK through the PROWORK study: PROmoting a Sustainable and Healthy Return to WORK. This involves the development and testing of toolkits for workers and line managers that aim to support sickness absence and return-to-work in mental health, through knowledge building, problem-solving, action planning, goal setting, and positive communication. ¹⁰ PROWORK is one example of a return-to-work intervention which aims to improve psychological and physical capacity among workers who are already off sick. This approach is supported by a systematic review and meta-analysis showing that training managers in workplace mental health can improve their knowledge, attitudes and self-reported behaviour in supporting employees experiencing mental health problems. ¹¹ Given the escalating rates of sickness absence, globally, due to mental ill-health, secondary- and tertiary-level interventions are essential.

Yet, given the public health and economic impact of the rising prevalence of mental ill-health at work, greater attention should be focused on primary prevention. With primary-level interventions, actions are taken to eliminate the underlying sources of stress or poor mental health in the workplace. Managers can play a pivotal role in fostering wellbeing in employees they directly manage, and more broadly across the organisation. Lecours et al. ¹² describe this as a ‘butterfly effect’, whereby the behaviour of managers towards their employees not only directly impacts employees’ mental health, but also influences whether employees engage in fostering mental wellbeing in others. Preventive interventions are far less commonplace than secondary or tertiary interventions – until recent years, guidelines for employers on mental health at work have tended to focus on the detection and management of existing mental health problems, rather than the prevention. We strongly advocate for the primary prevention of mental ill-health at work. One way to achieve this is through line manager training to raise awareness, change attitudes (i.e. reduce mental health stigma), and equip managers with the knowledge, skills, and confidence to initiate conversations about mental health at work, minimise stressful working conditions, and foster a psychologically safe team climate.

Training for line managers focused on the prevention of mental ill-health at work is limited and can lack rigour in development, testing and evaluation. Such programmes rarely consider the wellbeing needs of managers themselves, but this is important for managers to role model good practice and create positive working environments. We advocate for the provision of systematic training and support for managers in mental wellbeing self-care, psychosocial risk management, line management and communication skills, mental health awareness and strategies for employee support. This aligns with recommendations from the World Health Organization ¹³ and the UK National Institute for Health and Care Excellence Guidelines ¹⁴ outlining the importance of preventive and proactive strategic approaches to mental wellbeing at work. In the UK, our Managing Minds at Work (MMW) digital line manager training programme focuses on primary prevention of mental ill-health at work. It was developed through a rigorous collaborative-participatory design, ¹⁵ involving co-creation of content together with managers from organisations of varying types and sizes. The training covers five broad areas: (1) promoting self-care techniques among line managers; (2) designing work to prevent work-related stress; (3) management competencies to prevent and reduce stress; (4) having conversations with employees about mental health; and (5) building a psychologically safe work environment. MMW includes reflexive and experiential learning components to actively engage managers in the learning process. To date, we have established the relevance and value of MMW to managers across a range of organisations ¹⁵ and explored the feasibility and acceptability of the training to managers in different employment contexts. Moving forward, the effectiveness of MMW and other preventive interventions in improving manager and employer outcomes needs to be established in large-scale evaluations.