In 1891, Dr. Luther Gulick proposed a red triangle as the YMCA symbol. In his words, the equal sides of the triangle stood for “man’s essential unity– body, mind and spirit– each being a necessary and eternal part of man, being neither one alone but all three.” True then, and equally true today, it highlights what is missing from most traditional approaches to wellness–the mental, emotional, and spiritual components. Hardly surprising given the remarkable resistance mental illness treatments encounter.
The term “mental illness” usually refers to recognized mental illnesses in accordance with the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association. These include depression, anxiety, psychotic disorders, and bipolar disorder. While substance abuse and addictions are not so neatly categorized and are sometimes referred to as “behavioral disorders,” an indeed odd phrasing, we will refer to all such afflictions as “mental health or “mental illness.”
Through the Middle Ages, the mentally ill were believed to be possessed or in need of religion. This almost always led to serious religious interventions, barbaric medical treatments, alternative starvings and beatings, or confinement. None seemed to be very effective. In the 1840s, Dorothea Dix lobbied for better living conditions for the mentally ill. It took Dix forty years, but she successfully persuaded the federal government to fund the building of 32 state psychiatric hospitals.
Institutionalization persisted as the treatment of choice until the 1960s when Congress passed the Community Mental Health Centers Act of 1963, which deinstitutionalized all but those individuals “who posed an imminent danger to themselves or someone else.” By 2000, the number of state psychiatric hospital beds per thousand people was less than 10% of what it was in 1955. While “deinstitutionalization” continues to be hotly debated today, it represents an ongoing attempt to assimilate the mentally ill into society, just as we do for our physically ill.
The quest for mental health “parity” followed. Mental health parity proponents fought to remove differences between physical and mental health treatment, benefits, and coverage. While some states enacted partial parity legislation, little overall progress was made until 2008 when Medicare eliminated discriminatory copayments, and Congress enacted the landmark Mental Health Parity and Addiction Equity Act, which eliminated both financial and non-financial (e.g., maximum days; coverage limits) ways that insurers could limit access to addiction and mental health care. [Note: I’m proud to have been the only health insurance to testify in favor of the legislation.]
The inanity of some of these artificial limitations was obvious. Most insurance plans limited the number of mental health office visits (for counseling) to, say, thirty a year. For those truly in need of substantial counseling, when did the coverage run out? Just before the holidays, when they most needed it. People don’t overuse counseling. Just the opposite. And yet, this limit was inserted for God knows what reason. Such limits are outlawed today unless there are similar limits for non mental healthcare coverage.
Since enactment, mental health parity has continued to encounter resistance and difficulties. There is remarkable societal and professional resistance to recognizing and handling mental health issues the same as physical health issues. The stigma of mental illness has not entirely left us. Addiction continues to have overtones of moral reprehensibility and implied lack of will power or moral integrity. This is tragic, because it not only encourages sub par treatment–it also greatly frightens off those who might otherwise seek care or ask for help. And it places mental health advocates in the conflicting position of wanting greater confidentiality protections for mental healthcare than for physical healthcare.
Today we know that most people receiving care for mental health conditions also have related (sometimes called “comorbid”–a really odd descriptive) physical health conditions; and vice versa. We know that many forms of mental illness require physical health treatments in addition to counseling, and we know many forms of physical illnesses have tremendous mental/emotional components.
For example, where does one begin and the other leave off in the case of an obese, pre-diabetic, depressed, bullied, 14 year old girl with severe acne and abusive parents? Just seeing her pediatrician once or twice a year is suboptimal to say the least. Coordinated care amongst a psychologist, psychiatrist, social worker, PCP, and a specialist or two is optimal. Changing the culture of her environment? In a perfect world, yes, because without that, she may never recover full health despite good care. While we can’t always change the world, the parallels to workplace wellbeing seem obvious.
Healthcare delivery today is starting to see the benefits of co-located, integrated physical and mental healthcare, particularly in primary care patient centered medical home models. Some insurers are using innovative and very helpful funding techniques to advance this obviously needed change to how we deliver care.
When one considers the most common prescription drugs taken today, one can immediately see how one or more mental/behavioral components contribute to the underlying condition:
• Statins (cholesterol)
• Blood pressure meds
• Anti-depressants (Prozac, Lexapro, etc.)
• Sleep meds (Lunesta, Ambien, etc.)
• Digestive disorders (Pilosec, Nexium, etc.)
The above categories of drugs should not (with the exception of anti-depressants in some cases) be life sentences. These drugs should be prescribed with the goal of stabilizing physical conditions for a period of time needed to make one or more lifestyle changes to eliminate or lessen the behavior causing the underlying problem. For statins, blood pressure and digestive disorder meds, it usually is proper diet, exercise, AND the medications until a weaning can take place. With sleep meds and anti-depressants, it can be more difficult, but counseling and other activities should be undertaken with an eventual goal to reduce or eliminate the medication over time.
That is not happening in America today. Our delivery system treats the symptom rather than the underlying cause. We band-aid with meds and think we are healthier when our cholesterol and blood pressure readings are lowered to appropriate ranges due to the medications. We are not healthier; we are medicated or sedated.
Accordingly, we can see the powerful influence of the mental, emotional, and spiritual over our abilities to cope with the challenges of becoming healthier. They are all interrelated and interdependent.
An employee whose life is the antithesis of wellbeing stands almost no chance of engaging in long term behavior changes that lead to good physical health much less good mental and emotional health. We must see these truths for what they are and the remarkable opportunity that they represent. Because all analyses along these lines lead to the same conclusion: achieving company business and employee personal goals are interdependent and aligned. One needs the other. One feeds the other. And good employee mental, emotional, and spiritual health are critical ingredients.
Stress cannot be ignored. All employees suffer stress, some greater than others. While stress can be the result of situations outside the workplace (most notably family), they more often result directly from the workplace and its impact on employees. The American Institute of Stress tells us that long hours, lack of control, job insecurity, and perceptions of unfairness create stress that that adversely affects employee health and engagement, and is a barrier to positive lifestyle changes.
“Despite a growing awareness of the disturbing trend of ‘the overwhelmed employee,’ research shows that there is a pervasive failure to act in most organizations. According to the National Business Group on Health and Towers Watson’s 2013/2014 Staying@Work Report, the top wellness challenge identified by leaders is stress. Seventy-eight percent of leaders are reporting that this is their top concern, but only 15 percent of organizations are actually taking measures to address the issue.” Laura Putnam, Workplace Wellness That Works, p. 141.
A workplace that creates excessive stress for its employees is a breeding ground for bad health, excessive claims expense, disengagement, voluntary turnover, and absenteeism. It also can create personal tragedies for employees and their families. The very best antidote for such a situation is replacing such an environment with a culture of wellbeing that actively addresses the causes of excess workplace stress.
Contrary to popular belief, lack of money is not the primary cause of workplace stress. The most prevalent cause of workplace stress is actual or perceived unfairness, usually personified by immediate superiors who show no appreciation for those who report to them (i.e., jerks). There are way too many managerial jerks in organizations, because too many organizations promote employees to front line management levels because they were very good worker bees and producers in their former positions, rather than for demonstrated skills for managing people effectively.
Virgin Pulse’s 2016 Move Over, Wellness: Creating An Engaged Culture Through Wellbeing, tells us:
“Perhaps the most important factor in overall employee wellbeing is the relationships employees have with their immediate manager and co-workers. Research consistently shows that employees are more engaged at work when their leader cares about them as a person. Additionally Gallup research highlights the importance of workplace friendships and supports the idea that people who have high-quality friendships on the job are seven times as likely to be engaged in their work.”
Accordingly, any comprehensive and thoughtful attempt to achieve good employee health, wellness, and wellbeing must place emphasis on the physical, mental, emotional, and spiritual. It is beyond argument that to achieve good physical health, one needs sound mental health and wellbeing as enabling platforms, and vice versa.