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By Emil Vernarec

Employers have much to gain by promoting their workers' emotional health. Here's a menu of tips and tactics for budgets of all sizes.

Picture a workshop for a small group of employees. The leader asks them to name the biggest source of stress at work and the answers are plentiful: "The boss plays favorites." "Deadlines are unreasonable." "Clients are getting harder to please."

The next time stress boils over, the leader continues, observe not only your emotions but also the thoughts that preceded them. The more blaming and negative those thoughts "It's clear I don't count." "I'm trapped again in a no-win situation." "I'll fall apart at that meeting. "the more likely you'll become upset, down or otherwise unable to perform at your best. The challenge, says the workshop leader, is to recognize the distortions in those beliefs and replace them with more realistic perceptions as the first step to resolving the problem.

That scenario mimics a "wall-vaulting" exercise described in Martin Seligman's now classic book, Learned Optimism. Drawing upon his clinical work on preventing depression, Seligman taught readers techniques to develop emotional resilience. Now those same skills are being marketed to corporations not as therapy, but as a problem solving and productivity tool. What's remarkable is that skills that so explicitly address emotional health are now being accepted as contributors to business success.

With productivity demands rising and technology quickening the pace of life, there's no question that emotional health is on the minds of employees and employers alike. "What concerns most workers is the psychosocial domain," says Ron Goetzel, PhD), vice president of consulting and applied research at the MEDSTAT Group in Washington, D.C., "yet, the health promotion community only recently has put it on the front burner."

Persistent or severe stress is a risk factor for depression, an under treated disorder with profound personal and societal costs, including lost productivity. (See April B&H.) It also can lead to or worsen other medical conditions. Goetzel's study of the modifiable health risks of 46,000 employees showed that the likelihood of incurring any medical expenditures was highest for employees who reported symptoms of depression or high stress.

Ten years ago, when the Washington Business Group on Health received a government grant to develop worksite initiatives on depression, says Veronica Goff, vice president, "it was clear that employers didn't recognize that depression was a problem. We said, 'Look at your disability data!"' Now, employers that traditionally have provided workplace programs to help employees lower their cholesterol, weight and blood pressure are seeking ways to encourage emotional well-being. A number of them are bold enough to address depression directly.

Employers who do, says Goff, "don't pretend to be experts. Their role is to provide basic education and good benefits. While some want to raise awareness, they don't want the perception of invading privacy." But paradoxically, silence reinforces a significant barrier to treating depression.

First, address stigma

Stigma creates a pall of "shame and blame" woven from the belief that depression is somehow an individual's fault, the brand of a weak character or emotional feebleness. Where such attitudes are prevalent, many people would justifiably be wary of seeking help.

Think how this might play out in the workplace. Withdrawal, irritability, low energy and reduced motivation are common manifestations of depression. All could be mistaken for intentional indifference or carelessness. To complicate matters, the depressed worker may not realize that these are symptoms of a legitimate medical disorder.

"Depression is a real illness, but there are misconceptions about it among all concerned," says Joseph Bona, MD, vice chair, clinical affairs, with Emory University Hospitals in Atlanta and an associate professor of psychiatry. "While severe major depression is relatively easy to recognize, less severe cases are more ambiguous. The symptoms are vaguer, the patient may liken it to normal stress and be confused over what to do about it."

A good deal of that confusion derives from a narrow, biornechanical view of health that readily accepts physical dysfunction as illness but applies a different standard to psychological dysfunction. (Think of the resistance to recognizing "shell shock" as a real medical consequence of combat.) Yet, research has shown that biological factors play a significant role in depression. For example, processes in the brain that regulate mood, thinking, sleep and appetite are disrupted. And severe, prolonged stress produces physical changes that increase a person's vulnerability to depression. But cognitive factors-specifically how a person views and interprets stressful events-also are involved. Learned helplessness, for example, may develop as a result of trauma early in life, when an individual could do little about it.

"Biological and psychological factors predispose certain individuals to depression, just as some people have a predisposition to asthma," explains Judith Beck, PhD), director of the Beck Institute for Cognitive Therapy and Research, in Bala Cynwyd, Pa. "But while every illness has biological components, not every illness has cognitive or behavioral ones as depression does. Most crucially, just as you can't cure asthma by willing yourself to, depressed individuals can't simply pull themselves up by the bootstraps and be well.

"When faced with stressful events," she continues, , "most well-functioning people will do a reality check and move on to solving the problem. In depression, the difference is the intensity and number of symptoms. Depressed people are likely not to even be aware of the automatic nature of their negative thoughts, only the emotions. And they believe them as truth."

The good news is that progress in understanding the biological, cognitive and social factors that contribute to depression has led to better tolerated medications and more targeted talk therapies-so much so, that the Surgeon General's report on mental health says "the most salient problem is not with treatment, but ... getting people into treatment."

Because employers have so much to gain from emotionally healthy employees and because they provide a ready channel to educate adults en masse, mental health experts look to employers as potentially influential allies. Here are just a few proven tactics employers have chosen, from the very basic to advanced.

Mainstream mental health

The Surgeon General's report provides key messages to shape your communications about mental health care benefits-namely, mental health is fundamental to total well-being; mental disorders are real health conditions; and effective treatments are available.

In communication about EAP: Those messages also provide the rationale for integrating employee assistance programs with other benefits. "EAP is in orbit around our total health management," says Dan Conti, PhD), Bank One's EAP director. "You don't want to simply stick it on as a benefit. You need to give employees road signs on how to use it."

In workshops on health topics: L.L. Bean adapted an educational program on depression funded by an antidepressant manufacturer. EAP consultant Geoffrey Smith and a team of 10 trainers led 125 sessions on recognizing symptoms of depression and bringing them to a doctor's attention. Managers had liberty on how to incorporate the sessions into routine training. About 80 percent of Bean's 3,200 year-round employees took part. It didn't take much selling to management, says Smith, because "an illness that's high in prevalence, costly and under-reported but also treatable makes a juicy target."

Still, in some corporate cultures, using more general workshop titles like "Managing Your Mind" may be wiser. Goff says one firm finally got a response by calling the class "Depression in High Achievers." Because depression is common in people with chronic medical conditions like arthritis, cancer and heart disease, it can and should be at least mentioned in programs on those topics.

In management training: Simply put, managers need and appreciate expert advice on how to address performance issues when a referral to EAP is indicated. Magellan Behavioral Health, Columbia, Md., for example, dedicates a team of more than two dozen to guiding managers on how to clarify a problem, keep the focus on job performance and communicate with the employee supportively and without violating privacy rights.

Point the way to reliable information on depression

Print or electronic information offer a "softer" way to raise awareness. The first objective is to help employees learn the difference between normal feelings of sadness and a clinical disorder. The next is to help them understand available treatments and where to get care. Clear explanations of company mental health benefits are essential.

For consumer information on depression and its treatment, the government's www.healthfinder.gov site is a good place to start. Type in "depression" on the home search window and you'll find useful links to mental health organizations, on-line screening and resources from the Depression/Awareness, Recognition and Treatment program (for which WBGH developed employer materials). The National Library of Medicine offers an astounding wealth of resources at www.nlm.nih.gov/medlineplus/depression.html. (See box on page 37 for more web sites.)

Support opportunities for screening

Questions relating to stress, depression and anxiety often appear in general health risk assessments (HRAs) sponsored by many employers through third parties. Customized and public channels to depression screening are also available. Because anonymity is the drawing card, screening requires the most stringent privacy protections.

By telephone: Automated depression self-assessments debuted on the first National Depression Screening Day in 1990. The four-minute, voice-response program has since been sponsored by numerous hospitals and customized for over 300 employers. Nearly 70 percent of callers score positive for depression, says Nancy Vineburgh, program manager with Screening for Mental Illness Inc., the nonprofit organization that created the program.

"The screening is a bridge between awareness and intervention," says Vineburgh, "and provides total anonymity 24 hours, seven days." The screening, which is now available on-line at www.mentalhealthscreening.org, can also refer employees to a company's EAP or live health line.

Via computer: Web sites of many mental health organizations offer basic screening instruments free of charge to individuals. Custom-tailored screenings have the advantage of linking employees to their company s benefits. John Wasson, MD, who in 1983 led development of the first HRA for the Dartmouth Coop Primary Care Project (www.howsyourhealth.com), says such instruments should not only inform but encourage action. The Dartmouth HRA produces a one-page action form that individuals can bring to their doctor. In a current study of 2,500 people who used the HRA, says Wasson, 19 percent scored in the at-risk range on emotional problems, but only 60 percent said their doctors were aware.

Position, stress management as a personal health and performance issue

Time and stress management programs are standards of corporate training because they improve productivity. The two examples below are unique in their comprehensiveness and sophistication.

IBM's personalized program: Through its Intranet, IBM offers an interactive "Assessment and personal guide to handling stress" for its 120,000 U.S. employees.

The assessment takes about 40 minutes to complete and steps employees through nine potential areas of stress: job, family, personal, social, environmental, financial, muscular, emotional and cognitive. To identify specific concerns, each subsection prompts users with detailed questions, on which employees rank themselves. To ensure confidentiality, the results can only be printed, not saved.

The report that follows is instantaneous and includes an interpretation of one's score, explanations for why a user may feel under stress and advice for addressing its cause. The report also provides telephone numbers and links to IBM benefits, such as their clinical referral line, employee workshops and community resources. While the report does not diagnose, its tone moves from suggesting action to strongly recommending it, depending on an employee's scores.

"Simply taking the assessment has benefits," says IBM Nurse Program Manager Bernadette DelBene, who helped customize the program, "because you've identified and labeled the source of stress."

Skill training in resilience: Employers clearly benefit when workers effectively manage their thinking and emotions under stress. Some companies stick to basics like relaxation exercises, but resiliency training has brought a new level of sophistication to teaching skills that have personal and professional application.

The University of Pennsylvania recently licensed-to a company called Adaptiv Learning Systems in King of Prussia, Pa.-the tools psychologist Martin Seligman developed in his research on building resilience and preventing depression. Adaptiv has translated those tools into a corporate training program that applies these skills to dealing with pressure and change, improving individual and team productivity and handling adversity more effectively. The program has been piloted in a number of companies but is just beginning to be actively marketed.

The 12-hour program teaches seven skills centered around a ' core of cognitive therapy techniques that have been validated in more than 10 years of research. "The goal is problem-solving," says Karen Reivich, co-director of the Penn Resiliency Project and a vice president with Adaptiv, "based on understanding that one's initial beliefs may be inaccurate due to distorted thinking when you're under stress or on autopilot."

Distorted beliefs are almost always counterproductive. Magnified under stress, they can lead to frustration, a sense of loss or paralysis, anger and self-blame. "The Adaptiv skill-training," says Dean Becker, who heads the firm, "will not make systemic problems disappear or encourage employees to act as if the problems don't exist. Rather, participants learn to identify the problems accurately, accept their relative lack of control over them, and then move on and deploy their resources where they can do the most good."

Walk the talk

The programs outlined above assume a high value for employee health. Several of these tactics require only a series of consistent, repeated messages in company newsletters or on Intranets. Some firms, however, might steer clear of mentioning depression at all out of fear that doing so could drive up mental health claims. Other employers believe that the right intervention at the right time avoids needless suffering and even higher costs down the road. The difference in attitudes shows in benefits policy, in workplace climate and, very likely, in productivity. So much revolves around mental health.

"Often the most admired companies are organizations that have health enhancement programs and a philosophy of work/life balance," says Ron Goetzel. "That can make you look forward to going to work or try to avoid it. There's a big difference in performance."

EAP programs assume a competitive advantage at 3M

There's a refreshing directness to the way 3M talks about depression.

"We put it right out there," says psychologist Sheryl Niebuhr, PhD), director of EAP at 3M. "We normalize depression as an issue that sooner or later touches everyone through a family member, friend or co-worker."

Lunchtime educational sessions on depression-one for employees, one for managers have run since the mid-1990s. More recently, Niebuhr created a multifaceted program called "Resiliency" to enable employees to better understand and manage stressful events, large and small, on the job or in their personal lives. Both programs are part of broader initiatives that view health as essential to the success of the manufacturing firm, which employs 35,000 people in the U.S.

The employee workshop on depression debunks myths about the disorder and provides a guide for recognizing symptoms and seeking treatment. Managers team how to recognize that an employee might be troubled and respond effectively. The workshops are supplemented with booklets adapted from National Institute for Mental Health publications. 3M's program also publicizes the various help lines and behavioral health care benefits available to employees. As for the program's value to senior management, Niebuhr says that "it's not difficult to paint a picture of salience to business. It's hard to contest data that show everyone benefits from appropriate care."

3M's Resiliency program features over half a dozen workshops on the importance of mental health, a strong belief system, supportive relationships, a sense of perspective and problem-solving skills. These workshops touch on work (dealing with pressure, organizational change, conflicts with co-workers); personal life (divorce or loss of a loved one, chronic illness); and family (child raising, caregiving).

Joe Thompson, staff vice president of total compensation resources, describes the Resiliency initiative as a key corporate strategy on several levels. "Promoting the health and well-being of our employees and their families enhances the partnership between 3M and our employees, supports 3M's desire to be an employer of choice and contributes to our profitability."

The company is measuring the program's short and long-term impact on productivity. Niebuhr says there's already anecdotal evidence it will make a difference. In one division, the work groups that were meeting aggressive objectives and time lines were the ones that had participated in Resiliency workshops.

Before joining 3M nearly 10 years ago, Niebuhr directed mental health initiatives at the Wilder Foundation, which creates and funds community health and social services programs. She says their proactive approach shapes how she sees her current role. "What we find at 3M is that employees have busy, complex lives and they look for simple ways to get information they don't have time to get on their own," reflects Niebuhr. "I am struck by the powerful role employers can play."

Additional resources for employers and consumers

Mental Health: A Report of the Surgeon General

www.surgeongeneral.gov/

National Alliance for the Mentally III (NAMI)

Arlington, Va.

800-950-6264; www.nami.org

National Depressive and Manic-Depressive Association

Chicago, Ill.

800-82-NDMDA; www.ndmda.org

National Foundation for Depressive Illness Inc.

New York

800-239-1265; www.depression.org

National Institute for Mental Health

Bethesda, Md.

301-443-4513; http://www.nimh.nih.gov/

National Mental Health Association (NMHA)

Alexandria, Va.

800-969-6642; www.nmha.org

Washington Business Group on Health

Washington, D.C.

202-408-9320; www.wbgh.com

The third article in this series on depression will appear in September and cover efforts to improve quality of care.

Reprinted with permission from Business & Health 2000, Medical Economics Co., Montvail, N. J.