Moving Upstream: The case for a more proactive approach to mental health in the workplace

Published Tue, Feb 15, 2022

A person is walking along a riverbank and notices a man dragging people from the water. The man brings each person to safety on the bank and resuscitates them, one at a time. He tells the passer-by he is a doctor and explains that he’s been so busy saving these people’s lives, he’s had no time to venture upstream to discover why so many are falling into the river in the first place.

This ‘upstream’ health parable is attributed to Irving Zola, a medical sociologist and disability rights campaigner in the 1980’s, to highlight how the vast majority of medical practice was reactive rather than proactive. Dr Brian Marien, co-founder and director of The Positive Group suggested that medicine has genuinely started to work upstream as well as downstream but the focus in mental health, psychiatry and psychology, is still predominantly downstream. Tuning in from his base in Scotland, Dr Marien gave the keynote address at our recent CEO Forum – entitled Leading Mentally Fit Workplaces – which we hosted in partnership with the Business Council of Australia.

It was a fascinating speech, filled with rich and insightful pieces of wisdom. But it was this notion of ‘moving upstream’ that caught participants’ attention the most. Could the time that organisations spend reacting to problems related to workplace mental health be better spent, as Dr Marien posited, on a more proactive, ‘upstream’ approach? And if so, what would that look like in practice?

If I’m feeling good, flourishing and feeling well, my cognitive function will be optimal. I can get the best from my brain. My creativity, innovation, interest, dynamism and motivation will be good. My physical health improves and my behaviour is more prosocial and supportive.

Dr Brian Marien

The mental health continuum

According to Dr Marien, many people don’t seek help for their emotional or psychological issues due to the stigma, embarrassment and shame associated with a mental health diagnosis.

We know how powerful a barrier this stigma can be to people accessing early, preventative mental health support. According to Dr Marien, the key to breaking it down may lie in the way we conceptualise mental health in the first place. By understanding that emotional distress and psychological challenges are an inevitable part of the human condition, he suggested that if we can normalise stress and distress we can start to tackle the very roots of our shame around the issue.

We all move backwards and forwards along a mental health continuum, he explained. One end of the continuum represents good mental health where we feel as though we are flourishing and enjoy increased resilience, greater energy, motivation, creativity and cognitive fitness. The other end represents a decline in mental health where we feel as though we are languishing with an associated decrease in energy, engagement and focus.

Our constantly changing position on the continuum has huge implications for our cognitive function (concentration, memory, decision making and executive skills), physical health and behaviour. “If I’m feeling good, flourishing and feeling well, my cognitive function will be optimal,” Dr Marien said. “I can get the best from my brain. My creativity, innovation, interest, dynamism and motivation will be good. My physical health improves and my behaviour is more prosocial and supportive.”

Naturally, then, any decrement in psychological wellbeing will negatively affect cognitive function, physiology and behaviour. People with clinical depression, said Dr Marien, can lose 40–60% of their cognitive function. But if the depression is successfully treated, normal cognitive function is recovered. As individuals, where we are on the mental health continuum is extraordinarily variable from day to day and year to year, particularly in response to varying life circumstances. Any movement along the continuum can impact how we think, feel and behave. And the good news is that is something we have more control over than we realise.

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Neuroplasticity and mental health

Whatever a person uses their brain for, they get better at. If someone uses their brain regularly to learn French, play the piano or play tennis, they wire together many billions of neurons to support their task. In the words of neuropsychologist Donald Hebb: “neurons that fire together, wire together”. This is a process known as neuroplasticity. The same goes for thoughts, which Dr Marien told the forum can have huge implications for upstream mental health care.

Simply put, when a person is anxious they tend to have more anxious thoughts about themselves, about the world and about the future. These recurrent, repetitive, anxious thoughts, known as rumination, can strengthen their neural circuit for anxiety.

“The circuit goes from being a footpath to a bridleway to a B road to an A road to an autobahn, and it can become your screensaver,” Dr Marien said. “It can make you profoundly ill. And the reason I mention this is that most psychological problems – I would say over 90% – incubate and gestate.”

But we have an opportunity to intervene early on – an approach that would especially benefit young people. According to Dr Marien, mental health problems in those aged between 12 and 25 are a factor that predicts about 75% of all adult mental health problems.

“We need to help people understand what they are using their minds for because, inadvertently, they sometimes use their minds to get worse,” Dr Marien said. It is a trap we can all get caught in – a ruminative, neuroplastic loop.

We already have effective treatments. 50% of people treated with cognitive behavioural therapy (CBT) for depression and anxiety, ‘downstream’, recover during treatment and many others improve significantly. CBT has a very strong research and evidence base and has been shown to reduce the risk of relapse in many mood disorders – a finding that suggests it has a lasting protective effect. Accepting that our mental health isn’t a fixed proposition, that instead it’s an ever-changing movement along a lengthy continuum, we can start to embrace the kind of proactive mental health management techniques that are key to ‘moving upstream’.

“We need to begin normalising psychological health and periods of psychological distress,” Dr Marien said. “This has to start with leadership. There has to be an investment in prevention. It has to be valued, rewarded and seen to be important.

“If this can be seen as enabling, positive and helping your people to fulfil their potential and be the best they can be – cognitively, physically and behaviourally – it can be an exciting process of futureproofing.”

For Dr Marien, this must start with education.

We need to begin normalising psychological health and periods of psychological distress. This has to start with leadership. There has to be an investment in prevention. It has to be valued, rewarded and seen to be important.

Dr Brian Marien

Psychological education is key

We all know that we, as a community, have enormous work to do when it comes to learning about psychology and the ways it affects our lives. Dr Marien outlined how the scientific study of the human mind has seen extraordinary advances in the past few decades. Robust research is now actively informing the various factors that can nourish and deplete the human spirit.

When we feel anxious we tend to have anxious thoughts, more worries and concerns, and these anxious thoughts can serve to heighten our anxiety. The heightened anxiety then generates even more worrying thoughts. This process, known as cognitive-emotional fusion, rumination, can be modified by using effective, proven techniques for breaking the cycle and achieving cognitive-emotional de-fusion.

Dr Marien also mentioned “An important thing is how you feel about how you feel. If you get stressed about feeling stressed it can rapidly exacerbate existing stress levels. This metacognition, or meta-emotion, is a well-recognised risk factor for becoming ill.”

In most fields of medicine, we know now that understanding the risk factors and protective factors is important, but this is not as widely acknowledged in psychiatry or psychology. We often wait for people to be ill before we do anything. “We should be moving upstream and giving people good, coherent, evidence-based techniques,” Dr Marien said.

And the key, he suggested, is to do so while the issues are still manageable.

There is a powerful business case for moving upstream. Once any organisation has recruited capable and competent individuals the best predictor of their performance and productivity is their psychological health – it is the KPI.

Dr Marien argued that this type of education should also be in school curricula. “We need to teach our children these life skills,” he said. “Young people often struggle with emotional difficulties and the number of young people experiencing mental health problems is escalating. The number of young people presenting with psychological problems was already increasing prior to the pandemic. The young seem to have been particularly hard-hit, over the past two years, by the impact of Covid 19.

We now know that psychological education, understanding the things that exacerbate emotional distress and learning how to better manage emotions, is protective. We can all benefit from learning how to manage our minds more effectively”.

He also pointed out that this emphasis on upstream initiatives should not negate or diminish the importance of downstream interventions, good access to effective treatment, which absolutely need to be better funded.

“It’s not ‘either/or’. It’s ‘both/and’,” he said. “And I’m not suggesting this as a panacea. We will all fall in the river. That is not the issue. The issue is getting stuck in the river.

“But we need to teach people how to swim back to the bank. It is a concept sometimes known as anti-fragility. We can never develop a world in which we don’t get stressed, anxious, distressed or unhappy,” he concluded. “But what we can do is teach people the tools and techniques to recover a bit quicker.”

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