Prior to the pandemic, the United States saw a decades-long epidemic of “diseases of despair” with increasing rates of depression, suicide, addiction and overdose deaths. Mental health and substance use issues—and the economic and human costs of those conditions—were a focus for employers.
Then came the pandemic. Rates of anxiety and depression tripled and remain elevated months after the first COVID-19 cases were reported. Post-traumatic stress disorder (a complication of the coronavirus and a frequent response of frontline health care workers) appears to be rising in the general population, too.
We could become discouraged and give up hope, but that would be short-sighted. We know there are things we can do to mitigate the impact of behavioral health challenges in the workplace.[i] As Dr. Peter Sandman, a risk communication expert says, “We’ll get through this together.”
Oftentimes, employers are in the best position to help support employees with behavioral health challenges through existing programs or resources. I’d like to focus on an approach that seems under-appreciated: return-to-work (RTW) programs. These longstanding programs are generally associated with workers compensation or disability insurance claimants, but employees dealing with behavioral health conditions are often left out of these programs. That’s because it isn’t always easy to apply them to mental health or substance use conditions, even though we know they provide significant benefits for employees and their employers.
I believe there are at least four essential elements to any successful to RTW program – each of which should be considered when designing a RTW plan for an employee struggling with a behavioral health concern.[ii]
The First Element: A Holistic Approach
We have plenty of options to assist an employee who needs to temporarily stop working due to a physical condition: medical treatments, time off to allow healing, and accommodative equipment. There are also benchmarks that allow us to estimate how long this person will be out of work.
But with mental health conditions or addictions, the picture is much less clear. Medications and time off for healing are often needed, too, but some of the main elements of behavioral health treatment – especially psychotherapy and support groups – are less well defined and may seem clouded in ambiguity for an employer.
A successful behavioral health RTW program addresses both the individual’s mental and physical health needs. A significant percentage of employees with mental health and substance use conditions also have co-occurring physical health conditions such as chronic pain, diabetes, heart disease, and musculoskeletal conditions. Further, employees with behavioral health conditions may be more prone to accidents and injuries due to impaired concentration or fatigue related to their behavioral health issues.
Behavioral Health Conditions Always Exist Within the Context of a Person’s Life
But it goes beyond that. Behavioral health conditions always exist within the context of a person’s life. They impact the individual’s intimate relationships, their families and friends, their ability to work, their finances, their interests and hobbies – literally every aspect of their life.
To address these factors, a behavioral health RTW program needs to approach the employee holistically and provide a customized suite of solutions for each individual. That doesn’t mean the RTW program needs to offer all the services the person needs to recover. But it does mean that a broader spectrum of resources must be identified and presented to the individual as part of their RTW plan.
Integrating employee assistance, health management and community-based programs
Ideally, a behavioral health RTW program integrates the services available from the company managing the plan with both employer-sponsored benefits and the local community resources. This is most important with employee assistance programs since services available there may address a wide range of issues the employee is facing. EAPs generally provide services that support people in multiple areas of need: counseling for the behavioral health condition, marital and family therapy for intimate relationships, childcare and eldercare assistance, financial planning and review, and legal advice and referrals.
Other employer-sponsored benefits are also important in supporting an employee returning to work following a leave for a behavioral health condition. Employees usually access health insurance and pharmacy benefits prior to a disability leave, but other services such as disease management, wellness, peer-support, weight management, and smoking cessation programs may be helpful to continued recovery.
Beyond employer services, employees with behavioral health conditions frequently benefit from local community resources. Free or low-cost counseling, specialized services for people with specific needs (such as LGBTQ individuals or people dealing with domestic violence), community support groups, and assistance with necessities like food and shelter may all be part of a comprehensive RTW plan.
The Second Element: The Return-to-Work Consultant
The RTW consultant plays a central role in accessing and coordinating these various services. Ideally, this consultant is a trained professional who brings their education and experience in disability services to case management. This allows them to guide the employee through the complex experience of returning to work following an injury or illness that causes them to leave the workplace.
Ideally, the RTW consultant develops a personal relationship with the employee and understands their situation from the employee’s perspective.
In my work, employees who successfully returned to work following a leave related to mental illness or addiction concerns emphasize the importance of the support and encouragement the RTW consultant gave them. The personal relationship with the consultant may be crucial to motivate the employee to return to work, particularly in the face of setbacks or relapses.
Consultants must also access other professionals who can help address the full range of issues frequently present when someone is dealing with mental illness or addiction. When working with claimants with complex problems, RTW consultants who are not behavioral health professionals may need support from master’s- or doctoral-level clinicians. And prescribing professionals, including psychiatric nurses and physicians (preferably psychiatrists) can help the RTW consultant understand medication issues.
Employees with behavioral health diagnoses frequently include people with multiple, complex medical conditions who are seeing numerous providers and may be taking many medications.[iii] Unfortunately, these employees may not disclose to their primary provider that they are seeing other caregivers.
The RTW consultant frequently must explain to the employee the importance of including all providers in their RTW plan. These caregivers include vocational rehabilitation professionals, ergonomists, and occupational therapists who may support the consultant and provide input about unique accommodation strategies and equipment needed for a successful return to work.
Frequently, all these professionals may be employed by a company that also oversees leaves or treatment, such as a disability insurance, health insurance, or workers compensation carrier. Although they may also provide medical review services and professional opinions regarding issues such as authorization and payment of claims, those functions must be separate from consultations and case management provided with respect to RTW planning.
[i] I use the term “behavioral health” as an umbrella term, encompassing both mental health (psychiatric) and substance use (alcohol & drug) issues and conditions, but there isn’t clear consensus in the field and some people use “mental health” as the overarching term. I also use the term “addiction” as synonymous with problematic substance use conditions.
[ii] Note that legal issues that are relevant to return-to-work programs, such as FMLA, ADA, OSHA standards and state workers compensation statutes are outside the scope of this article. Interested readers should consult appropriate legal resources with respect to compliance with those and other regulatory requirements.
[iii] These employees are also often the ones identified as utilizing a disproportionate level of medical and pharmaceutical benefits, as well as repeated sick leaves, workers compensation leaves, and disability leaves. They may be well known to their employer’s HR Department because of their complex needs, and a side benefit of working with a return-to-work consultant is that the consultant may become the primary point of contact for the employee, thus relieving the HR Department of some of the difficulties associated with helping these employees navigate their complex health needs.