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Mental Health Has Become a Business Imperative

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Of the many issues we have faced throughout the past two years, perhaps the most surprising but important is mental health. Studies now show that nearly 81% of workers face some form of burnout or mental health issue, and 68% of employees say their daily work has been interrupted by these challenges. 1

Health care is one of many industries, along with retail, transportation, and hospitality, that has been especially affected by burnout and stress as a physically and mentally depleted workforce has faced peaks in demand for services.

Large health care providers like Provident and HCA, among others, have told us that their employees are “undergoing trauma, just like our patients.” This, in turn, is leading to sickness, absenteeism, and staff turnover. There’s a domino effect on remaining teams, too, as these employees are overstretched and unsettled and face high levels of stress in order to meet patient needs with fewer people.

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From our regular discussions with HR leaders around the world, it’s clear that the organizations outperforming their peers are those that have cultivated a strong sense of empathy and flexibility, developed new skills to address workforce needs, and extended holistic mental health support to employees.

Like many of the changes that have come out of the pandemic, this new approach to mental health looks set to be a permanent one. As they begin to see the value in the link between mental health and the well-being and overall performance of a business, leading companies are going the extra mile to understand and respond to the way employees feel day to day.

The CEO of Starbucks has stated publicly that he considers the mental and emotional health of the company’s workers to be its biggest challenge coming out of the pandemic. 2 Morgan Stanley, which employs many people who have advanced degrees and are exceptionally high performers, now has a chief medical officer dedicated to maintaining and improving mental health across the organization.

Within human resources departments, we’re seeing a growing trend of companies promoting new roles focused on measuring and improving mental health at work.

Our research (a study of over 1,000 companies) examined which business and people practices have the most impact on business outcomes, people outcomes, and innovation. This analysis points to the importance of transitioning from the traditional focus on employee benefits to one that encompasses job and work design, management, rewards practices, a demonstrated commitment to psychological safety and fairness, and a culture of employee listening.

This research shows that “healthy” organizations outperform their peers in a range of ways. Rates of absenteeism are almost 11 times more likely to be lower, and these employers are more than three times more likely to retain people. Companies that care about staff well-being are at least twice as likely to delight customers, to be identified as a “great place to work,” and to exceed financial targets. These companies also adapt more readily to change and are more effective at innovating . 3

From HR Issue to Management Priority

We’ve found that within organizations, the higher up that mental health is prioritized, the bigger the impact of any interventions. Until recently, mental health was seen as a benefits problem, relegated to the realm of HR. Companies offered employee assistance programs, for instance, or insurance-provided advice networks to help staffers find a counselor. These programs, while widely available, were rarely used in practice, due to employees’ worries about the stigma of asking for help. Plus, benefits managers were continuously concerned about the programs’ cost.

Now, this equation has changed completely. Mental health is scaling the management agenda, and money is being made available to invest in identifying and addressing issues with positive, proactive, and increasingly creative solutions.

Pioneering companies are creating programs for sabbaticals, time off, child care benefits, and far more flexible work arrangements. Tools like real-time pay systems , regular feedback sessions, the four-day workweek , and far more discussions with leadership are all efforts to make work more humane and healthier for workers. Simple policies like allowing dogs in the office can cost so little yet matter so much to employees.

In many cases, technology platforms and targeted apps are providing some of the answers — from meditation apps geared toward mindfulness to tools that improve the employee experience by helping to alleviate administrative strain. But for maximum and lasting impact on mental health, change needs to happen within the context of culture, where conversations about mental health are encouraged and normalized.

Any good, proactive mental health initiative starts with listening. Most companies, and most business leaders, won’t know how much stress there is in the organization unless employees tell them. Sentiment surveys, open town hall meetings, and exit interviews are all crucial inputs for gathering facts and bringing attention to the issues employees are facing.

The real shift here is that many companies are now removing the stigma attached to talking about matters of mental health. People can say, “I’m not feeling well today,” or “I’m tired,” or “I’m having troubles at home”; that type of feedback is critical.

Monitoring in this way will help senior managers pinpoint any particular hot spots in the business for further investigation.

Innovation in Action

During the pandemic, the leadership team at global telecommunications provider Verizon created a series of biweekly conference calls to help senior managers empathize with the high levels of turnover, stress, and employee burnout in its field force and share ideas on how to address these urgent issues.

JPMorgan Chase implemented a well-being application for all of its employees that asks staff members and leaders to check in regularly to tell the system how they feel that day. HR monitors these signals and data inputs to see whether certain groups are experiencing major changes in stress, enabling HR team members to connect managers and challenged teams with support.

Royal Bank of Canada requested that all managers take a course in mental health, developed by the public mental health council of Canada. This course helps leaders develop skills for recognizing various forms of stress or other illnesses, using the language of mental health.

Airline reservation and technology company Sabre surveyed employees regularly to understand their stress and productivity challenges in the move to remote work. Using this input, the company shifted to a new management model, creating a set of focused tools for managers to diagnose, improve, and continuously monitor employee stress and productivity.

Toward the Genuinely Healthy Organization

Creating a robust and consistent process for monitoring employee well-being allows employers to spot issues before they escalate and to provide timely help. Encouragingly, of the 1,000-plus companies we studied, about 15% now think about overall employee well-being as an integrated part of their strategy .

Related Articles

This has implications for leaders’ skill sets and personal attributes, too, which over time will have a bearing on who is promoted into senior roles. I believe very strongly in human-centered leadership — the idea of putting your people first and prioritizing their health. Managers or team leaders have to keep in mind that people’s sense of safety and security is the most important thing. Once that’s in place, you can talk about everything else. But if that isn’t there, everything else you’re working toward will suffer.

Now more than ever, it’s time to think about the employee experience more holistically. It isn’t just my own work that’s highlighting this. Study after study shows that mental health is the top-rated benefit requested by workers. In response, leaders, managers, and employees at all levels must advocate for a proactive approach to mental health. It’s both the right thing to do and a solid business strategy.

About the Author

Josh Bersin ( @josh_bersin ) is a global industry analyst covering HR, talent, and leadership and is the founder of the Josh Bersin Academy.

1. “ Employer Support Has a Direct Impact on the Health and Resilience of Employees, According to a Mercer Survey ,” Mercer, Sept. 13, 2021, www.mercer.com; “American Worker in Crisis: Understanding Employee Mental Health in Unprecedented Times,” PDF file (Burlingame, California: Lyra Health, July 2020), https://get.lyrahealth.com; and “ Edelman Trust Barometer 2022 ,” PDF file (Chicago: Edelman, January 2022), www.edelman.com.

2. A.R. Sorkin, “ Howard Schultz: Starbucks Is Battling for the ‘Hearts and Minds’ of Workers ,” The New York Times, June 11, 2022, www.nytimes.com.

3. J. Bersin, “ The Healthy Organization: Next Big Thing in Employee Wellbeing ,” Josh Bersin (blog), Oct. 27, 2021, https://joshbersin.com.

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Ideas and insights from Harvard Business Publishing Corporate Learning

Opening up About Mental Health at Work

Last summer, American gymnast Simon Biles won the admiration of many when she withdrew from several Olympic events for mental health reasons. Biles is one of a growing number of high-profile individuals who have recently shared personal mental health struggles. Olympic swimmer Michael Phelps. Superstar Lady Gaga. Prince Harry. All have used their platforms to bring mental health issues to the fore.

When celebrities voice concern about their mental health, they raise public awareness and help reduce stigma. But how does this heightened attention to mental health affect the workplace?

The numbers are telling Mind Share Partners is a nonprofit organization focused on mental health at work. In the spring of 2021, they conducted a survey of full-time employees in the United States. Their findings, revealed in Mind Share Partners’ 2021 Mental Health at Work Report in Partnership with Qualtrics & ServiceNow , are eye-opening.

Over three-quarters (76%) of respondents indicated that they experienced at least one symptom associated with a mental health condition in the past year. This was up from the already significant percentage (59%) found in a similar 2019 Mind Share Partners survey. The most frequently reported symptoms were burnout, depression, and anxiety, and these challenges aren’t fleeting. For more than one-third (36%) of those surveyed, symptoms persisted from five months to a year. Employees at all levels experienced mental health symptoms, with slightly greater instances reported by executives (82%) and C-level professionals (78%).

Mental health challenges have a profound impact on an organization. One-sixth (17%) of respondents said that they missed more than 10 days of work in the past year because of mental health challenges. Further, 77% experienced a decline in productivity due to mental health. And an astonishing one-half of those surveyed said that, at some point during their career, they left a job due to mental health concerns.

Absenteeism. Productivity. Retention. It’s no wonder that organizations are beginning to pay serious attention to mental health. “Mental health challenges,” as the Mind Share report’s authors wrote, “are [now] the norm.” Other global research confirms the Mind Share Partner findings.

Deloitte conducts an annual survey of millennials (and now, Gen Z as well) to identify trends involving the digital natives who are rapidly coming to dominate the workplace. Deloitte’s 2021 Global Millennial Survey Report noted that nearly one-third of respondents said they’ve taken time off work “due to stress and anxiety caused by the pandemic.” Among those who didn’t take time off, 40% indicated that, even though they chose to go to work, they were “stressed all the time.“

Why now? What’s causing unprecedented levels of mental health issues in the workplace? As Deloitte found, the pandemic is a significant driver. But it’s not the only factor. There are myriad other factors that combine to exert pressures that affect our mental health. Globally, there is political unrest and significant polarization. Environmental concerns including climate change weigh heavily on people’s minds, especially among those in the rising generations. There are heightened concerns over the growing wealth gap, over racism, over diversity and inclusion of populations that have long been marginalized. And, on top of all these issues, they’re also stressed about the need to find purpose and do meaningful work.

Organizations respond to mental health concerns Fortunately, as employees increasingly become more transparent about their mental health challenges, organizations are stepping up to help address them. In many cases, the pandemic gave businesses the immediate need – and the opportunity – to tackle issues around workplace flexibility. Senior leaders, experiencing mental health challenges of their own, are reaching out to employees with greater authenticity. They’re hearing and acting on concerns about diversity, equity, and inclusion, and about purposeful work. And they’re acknowledging that a focus on mental health is no longer a ‘nice to have’ but a necessity in the 21st century workplace.

Let’s talk

Change isn’t easy, but we can help. Together we’ll create informed and inspired leaders ready to shape the future of your business.

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What Will It Take to Confront the Invisible Mental Health Crisis in Business?

As a finance specialist, Harvard Business School Professor Lauren Cohen works to understand the dynamics that make businesses thrive. In his recent research on family companies, he has found one common thread among successful firms: They actively support their employees’ mental health.

One of Cohen’s recent case studies spotlights Zak Pym Williams , the son of the late comedian Robin Williams, who is spreading awareness about mental illness after struggles following his dad’s suicide. Another case highlights the Staglins , a family of winemakers whose founder, Garen Staglin, started a brain health research fund after his son experienced a psychotic break.

In the following interview, Cohen, the L.E. Simmons Professor of Business Administration at HBS, discusses why it’s important for organizations to address mental health and how executives should handle pressure at the top.

“Mental health has risen to the fore.”

Kara Baskin: As a business school professor, why are you interested in mental health?

Lauren Cohen : I got interested based on the two streams of the work that I do. The first has to do with understanding what makes firms tick and what detracts from them. Within every industry, [employees] have become more important.

Also, my [research] focuses on families. Families run a large percentage of the world’s organizations. How do these families work? How do they make decisions? What can cause them to unravel?

Mental health has risen to the fore. It’s wonderful, in the sense that this is something that needs to be tackled, but also worrisome and scary in some ways, because you see just how many blind spots we have and the magnitude of the problem.

Baskin: What is the magnitude of the problem?

Cohen: There is a public stigma to mental health ailments. Here are seven of the common misperceptions around mental health that contribute to the stigma:

• A person’s mental health issue is just an “excuse.”
• “It’s going to be a burden to our business or organization if we take on this person who has a mental health issue.” There’s a cost, stability, or consistency concern.
• It’s associated with weakness. “Just pull [yourself up by] your bootstraps. This isn’t what your grandparents did.”
• Self-fault. “You’re doing something wrong. You’re not dealing with this the way you should.”
• The group may see it as their own failure. This is especially true in a family. “Oh, it must’ve been something we did wrong in raising our child.”
• It’s unsafe. “We’d love to include this person as part of organization, but it’s not safe to, because of this mental health issue.”
• The “not my neighbor” phenomenon, which is: “We should definitely embrace mental health concerns and issues, just not in our division.”

Now, the key to breaking the tie between these misconceptions and the stigma lies in rigorous persistence and sequential focus. Do not attempt to solve all of these in one fell swoop. Choose one misconception, and create an engaging, open, ongoing forum where it can be addressed, examined, turned-over, then re-examined. This setting maximizes the chances of employees on their own seeing how disconnected the misconception truly is.

“Understanding all of the aspects of your employees is going to make you a better organization.”

Baskin: Why should organizations think about mental health, especially people who want to be good leaders?

Cohen: Your workers are with you eight hours a day, but what happens in the other 16 is going to have a huge impact on what occurs during the eight that they’re with you.

Understanding all of the aspects of your employees is going to make you a better organization. Even if you were to say, “My job as a manager is to forget about being a friend. Forget about being a human. Forget about being a person. My job just as a manager is to make sure that I somehow maximize something here. I run the tightest ship.”

Even if that were your main goal, this would still be a front-and-center issue, because this has such an impact on employees and their lives during their eight hours.

Baskin: What can businesses learn from the recent cases you’ve written?

Cohen: The main takeaways from both of these cases are that being a leader, and a true hero in this still-forming space, can start with one conversation, one email, one question. Every marathon starts with a single step, and you'd be surprised at where that step can take you. I know personally that Zak Williams and Garen Staglin are.

Baskin: There’s a perception that senior leaders are impervious to mental health struggles. What can be done to better support people at the top?

Cohen: This is a great point. There was a paper looking at the deaths of executives and what happens. Firm profitability and other value measures go down, as you might expect.

But what’s even worse for firm value is when one of the executive’s close family members dies. Because then the executive stays on, but they are going through the mental anguish of having lost someone who’s very close to them.

It highlights in a really powerful way, just from raw data in the real world, what happens when you have an executive who has dealt with this.

Baskin: How do leaders take care of themselves?

Cohen: Each case is different. If you force a leader who’s clearly uncomfortable and doesn’t want to talk about it to open up, it may make them a worse leader: “Gosh, now my focus is on this and how I’m going to present this to employees and how they’re going to view me.”

Each leader has to decide what they’re comfortable sharing and not sharing. I don’t think that a leader has to say, “Hey: Here’s my struggle with mental health.” They can just say, “This is something that’s important to our organization, and so we are now going to consider mental health on par with physical health. They’re equivalent.” I think that’s enough.

The truth of the matter is that businesses are part of a solution, but if it started and stopped there, this would never work. It also has to be in the home. It also has to be in a public sphere. It has to be everywhere. I view business as just one piece of this.

Baskin: How do you do this without a mandatory, “We’re going to gather at lunch and talk about our mental health?”

Cohen: If you create an environment where people have the slack to do this, rather than causing it from the leader-side, I think that’s better. People who organically do want to talk about this and who feel comfortable start to talk about it, and more people will. And, honestly, some people may never want to talk about this—and that’s OK.

You just say, “This is going to be something that we as a firm recognize is an important part of people’s lives. We’re giving you all the slack. Those of you who want to take it, great. If you don’t, great. It’s totally up to you.” I think that will generate [exposure] in a much more organic way.

Editor's note: If you or someone you know needs help, call or text 988 to reach the National Suicide Prevention Lifeline in the US. You can also call 800-273-8255.

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Feedback or ideas to share? Email the Working Knowledge team at [email protected] .

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The Impacts of Employee Mental Health in The Workplace: A Literature Review

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How these organizations are leading in making employee mental health a priority

Learn more from these case studies of successful leaders promoting mental health among workers.

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Psychological evidence suggests employee mental health is a critical component for organizational functioning and success. As with any positive business outcome, promoting mental health among your workers often requires a significant investment of time and resources.

If you’re dedicated to equipping your employees and organization to thrive but you don’t know exactly where to begin your efforts, learn from these organizations, who have taken steps to prioritize employee mental health.

American Psychological Association

APA’s science-led, empathy-based culture has always informed its approach to employee mental health. To ensure employees can access psychological support necessary to thrive in their personal and work lives, APA provides a robust package of mental health benefits.

Employees can access mental health care for a low copay through APA’s insurance provider or through an additional mental health care insurer that enables employees to access any mental health professional for only a $20 copay (with the exception of employees enrolled in a high-deductible Health Savings Account plan, to which APA contributes).

In addition, APA’s employee assistance program provides employees and their household members with free, confidential, 24/7 support to help with personal or professional matters that may interfere with work or family responsibilities.

APA found new opportunities to build on its ongoing dedication to employees’ mental health and well-being during the Covid -19 pandemic, starting by ramping up internal communications that instilled a much-needed sense of belonging during the transition to remote work and continues to solicit employee feedback that informs organizational policies, programs, and procedures. For example, the daily staff e-blast, APA Today , is now shared in video and text format, staff share fun personal photos through questions of the week, staff are given a few extra days off per year for strengthening mental health (in addition to a generous PTO plan), and staff can share with each other socially through themed Microsoft Teams channels and Coffee Connections meetups.

Along with considering employees’ needs and interests, new initiatives also weave in the latest psychological science about what employees and organizations need to thrive. Additionally, APA uses a cross-departmental approach to implement changes, in which experts in the areas of human resources, psychological science, employee well-being, as well as C-suite leaders, work together to communicate about employee and organizational needs and implement initiatives.

APA conducts regular “pulse” polls to survey employees about the level of support they feel from their managers and the organization and what they need to feel more supported, from computer hardware to more flexible working hours. Employees also have an opportunity to hear updates from and share concerns directly with APA’s CEO in a biweekly, virtual chat.

To address the multiple layers of stressors employees are facing, APA initiated multiple staff conversations around racism and related current events, inviting experts to speak about the issues and how to take action. Employee resource groups were formed to support employees and provide them with a community.

APA also assembled a working group to use lessons learned during the pandemic and employee feedback to plan the future of the organization’s workplace. Most employees (75%) participated, sharing their perspectives about the future of work via focus groups, conversations with leadership, pulse polls, surveys, or other forums.

In response, APA is evolving its concept of the workplace rather than simply returning to prepandemic office norms: APA established a flexible work policy that allows employees to move outside the Washington, D.C. area to one of 40 approved states, maintaining their current salary and same level of employee benefits no matter where they move. In response to employees’ desires to improve their work-life harmony, APA also implemented a Meet with Purpose campaign that encourages science-based best practices for all internal meetings. Each meeting needs to have a designated agenda, start on the hour or half-hour, and last for 25 or 50 minutes to ensure employees have breaks between meetings to tend to personal or family needs. Employees are also encouraged to consider and communicate to the team about whether video is required for a meeting or if it can be audio-only, since back-to-back video meetings can have a negative impact on employee well-being.

Blackrock, an international investment management organization, also recognized the urgency of prioritizing employee well-being during the Covid -19 pandemic. As the organization pivoted to remote or socially distanced work, it conducted periodic employee surveys to gather feedback that would inform new policies and procedures.

For example, Blackrock extended its health care coverage to ensure employees working out-of-state or out of the country, along with their families, could access health care. To better support employees’ mental well-being, Blackrock onboarded a new employee assistance provider to help deliver a range of new mental health benefits, including care navigation, easy online appointment booking, virtual care delivery, and a high-quality network of providers integrated into its medical plans. The firm also offered a company-paid subscription to the Calm app and launched a peer network of Mental Health Ambassadors.

To support employees with family responsibilities, the organization expanded the number of company-paid back-up care days, implemented more flexible work-from-home schedules, and encouraged the use of the existing flexible time off policy that allows all employees—regardless of title or tenure—access to paid time off as needed. To encourage employee collaboration, Blackrock also created online forums for sharing ideas and resources to support parenting and childcare.

Building on psychological research about the importance of manager support, Blackrock launched a series of enablement sessions to train supervisors in keeping their teams informed and motivated. The firm also created an intranet resource hub to streamline internal communications, so employees can quickly access information they need to do their jobs well and ask for help as needed.

YMCA of the USA

YMCA of the USA, (Y-USA), the national resource office for the nation’s YMCAs, pivoted to fully remote work in March 2020. Recognizing the increased need for social and emotional support, YMCA immediately began heavily promoting its employee assistance program (EAP) services through frequent newsletters, emphasizing free access to confidential services for employees’ entire families.

To learn more about additional unmet needs, Y-USA leaders also utilized pulse surveys in which employees rate various areas of well-being. Using this feedback, leaders made distinct efforts to implement changes. For example, when one survey found that many work-from-home employees needed additional office equipment to perform their jobs well, the organization provided it. Another survey made clear that employees weren’t ready to return to in-office work in 2021, so YMCA changed its plans and extended its flexible work policies.

In response to employee concerns about lack of camaraderie, Y-USA created weekly virtual Coffee Chats to connect employees with one another and Tech Tuesdays, an opportunity for employees to learn or refresh tech skills, ask tech questions, and learn about efficient hybrid work practices.

Biannual culture surveys conducted by a third party also guide Y-USA’s practices. To continue to ensure employee feedback is carefully implemented, Y recently formed a Culture Counsel of volunteer employees, who help review areas for improvement and discuss possible changes. After learning of employees’ continued desire for work flexibility, organization leaders extended the work-from-home practice, encouraging employees to visit the office as needed.

In addition, Y-USA convened a Mental Health Thought Leader Cohort, made up of local Y staff who curate and package “To Go” mental health kits, a grab and go resource for local Y leaders to implement with staff, such as “Dinner Table Resilience” which offers short videos, tools, and strategies for Y-USA staff and members to use at the dinner table with families to build resilience skills.

F5 Networks

F5 Networks, a large technology company in the Seattle area, also uses employee surveys extensively to promote its “human-first, high-performance” culture. Along with regularly surveying existing employees, leaders also seek input from candidates who weren’t hired, employees who left the company, and individuals who left and came back.

After learning how growth opportunities led to employee retention, F5 developed a company-wide mentorship program, increased its budget to allow employees to pursue continued education in their field, and created quarterly learning days on which employees have no internal meetings but instead focus on learning.

In response to an increased need for time off—without the stress of returning to an inbox full of emails—F5 also launched company-wide quarterly wellness weekends allowing all employees an extra paid consecutive Friday and Monday off.

Ongoing survey data suggest positive business outcomes. F5 employees report feeling more refreshed and ready to tackle projects when they return to work after time off, for example. In general, F5 staffers report feeling supported by their managers and the organization as a whole.

On its U.S. medical plans, F5 also removed out-of-network restrictions for psychotherapy to ensure employees could connect with diverse therapists and therapists not accepting insurance. Rather than paying a large deductible and being partially reimbursed for services, employees on the Preferred Provider Organization plan pay a $15 copay for any therapist (plus any additional fees if the therapist charges more than what the benefits cover). Additionally, F5 increased its EAP therapy visit max from three to five annual sessions per employee.

Ernst & Young

The consulting firm Ernst & Young (EY) offers a full suite of mental health and well-being resources for employees and their families. In addition to EY’s health care plan that includes mental health benefits, EY has an internal team of clinicians that conduct presentations and interactive sessions promoting mental health in the organization.

EY also works with a private vendor to offer up to 25 psychotherapy sessions for each employee and each person in their household per year. Because employees’ family lives can impact their well-being and work performance, the firm extended the mental health benefit to include all family members in the household including children, domestic partners, and relatives, regardless of their age or whether they’re on the employees’ health care plan. The network of clinicians represent a variety of backgrounds that can meet employees’ diverse needs. They use evidence-based psychotherapy practices to ensure the best outcomes.

EY recognizes the role of psychological concepts like resilience in staving off stress and burnout. EY allows employees to access mental health coaching sessions to prevent issues that could interfere with well-being and work performance and increase overall well-being in their daily lives. Data suggest employees working with a mental health coach or therapist saw an 85% improvement or recovery from the initial reason they sought care.

For people who would rather use digital tools, EY offers a positive psychology-informed app that educates employees about coping with stress and promoting resilience through articles and activities. Similarly, a digital sleep resource provides personalized guidance for improving sleep. On average, people using this digital tool are getting an average of four more hours of sleep per week.

An internal initiative called We Care educates employees on important topics such as recognizing signs of mental health concern and addiction and best practices for offering support. Employees share their own mental health stories to destigmatize the topic. To encourage time away from work, EY also reimburses employees for vacations and travel; the company also reimburses for physical wellness-related activities, such as gym memberships, fitness equipment, and even mattresses.

National League of Cities

The National League of Cities (NLC), the nonprofit advocate for municipal governments, is committed to supporting and nurturing a work culture that prioritizes the mental and physical health of its employees. It has done so through several targeted approaches. Like many organizations, NLC moved its entire 130-person Washington, D.C.-based staff to virtual work at the start of the pandemic. Employees were encouraged to maximize and leverage flexible schedules. As the pandemic evolved, NLC developed a hybrid model in which staff could continue to work remotely and also use the NLC offices for collaboration and other onsite work.

The organization’s health insurance plan covers mental health services on par with its coverage of physical health. NLC subsidizes coverage for employees and family members, including access to licensed mental health providers who offer services via telehealth. NLC also offers an EAP, which it promotes regularly (and even more frequently during the pandemic) to employees.

At the start and during the height of the pandemic, NLC gathered employee input. NLC surveyed employees in 2020 and 2021 to learn about their telework experience and hear their return-to-office concerns and suggestions. More than 90% of the staff participated. To determine the cultural norms for hybrid work, NLC used a dispersed decision-making method that employed focus groups to gather ideas from every employee in the organization. One resulting cultural norm the company has established, is that employees are highly encouraged to use their paid time off from work to unplug and refresh.

American Public Health Association

The American Public Health Association (APHA), a Washington, D.C.-based organization for public health professionals, champions the health of all people and all communities.

When Covid -19 struck, APHA’s staff worked harder than ever to develop essential Covid -19 resources for members. At the same time, employees were experiencing the loss of loved ones, isolation, racial inequity, financial burden, family job loss, and the need to provide around-the-clock family support. These strains caused a real need for mental health services and support.

How does APHA support its staff? APHA’s EAP, a free service for staff, offers three immediate counseling sessions with a licensed mental health professional. Staff can access EAP professionals 24 hours a day, 7 days a week. The EAP can also provide legal assistance, online will preparation, financial tools and resources, help addressing substance misuse and other addictions, as well as resources for dependent and elder care.

APHA’s mental health services through their insurer, CareFirst, are tailored for short-term and long-term mental health matters. Employees and covered family members seeing in-network professionals have no copayments and many of the providers offer telehealth visits from 7 a.m.–11 p.m. Eastern time, 7 days a week. The average therapy appointment is about 45 minutes. Psychiatrists are also available to help with mental health conditions requiring medication management.

Staff are encouraged to voice their needs. APHA instituted several internal services and activities to improve how management listened and responded to employee needs. “Courageous Conversation,” started after the George Floyd and Black Lives Matter protests, are discussions with peers in an honest and safe environment about experiences that relate to race. During the height of the Covid -19 pandemic, Half-day Fridays gave staff a mental health break from the stress of having inseparable work and home space. A mindfulness video APHA shared with staff reminded them to be present in the moment, take a breath, and tackle one thing at a time. While working from home, No Meeting Tuesday Afternoons ensured staff had a block of time to focus on one task at a time as they navigated the stresses of the pandemic and increased virtual meetings. Optional forums and surveys allowed staff to communicate their mental health needs and challenges. Complimentary Stretch Class—a free monthly service—gives staff a 45-minute break to relieve stress and tension.

5 ways to improve employee mental health

Supporting employees’ psychological well-being

Striving for mental health excellence in the workplace

Acknowledgments

APA gratefully acknowledges the following contributors to this content.

• Tammy D. Allen, PhD, professor of industrial and organizational psychology at the University of South Florida
• Christopher J. L. Cunningham , PhD, professor of industrial-organizational and occupational health psychology at University of Tennessee at Chattanooga
• Gwenith G. Fisher, PhD, associate professor of occupational health psychology at Colorado State University
• Leslie Hammer , PhD, professor of occupational health psychology at Oregon Health & Science University and codirector of the Oregon Healthy Workforce Center
• Jeff McHenry, PhD , principal at Rainier Leadership Solutions and faculty member at USC Bovard College
• Jon Metzler, PhD, director of human performance at Arlington, Virginia-based Magellan Federal
• Fred Oswald, PhD , professor of industrial and organizational psychology, Organization and Workforce Laboratory, Rice University
• Dennis P. Stolle, JD, PhD, senior director of APA’s Office of Applied Psychology
• Ryan Warner , PhD, founder and chief executive officer of RC Warner Consulting in Albuquerque, New Mexico

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The Mental Health Crisis: A Toolkit for Business Leaders

Supporting employee mental health in the post-pandemic workplace..

Posted June 5, 2021 | Reviewed by Devon Frye

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• Mental health problems have skyrocketed, resulting in a drop in productivity and a rise in costs for businesses.
• With some guidance from mental health experts, employers can support the strength and resilience of their greatest resource: their people.
• To address mental health, create a culture of wellness, practice compassionate leadership, and provide access to direct services.

As Americans ease tenderly out of the pandemic, one thing is clear: mental health is not going to rebound rapidly just because the masks come off. Anxiety and depression rates have tripled since the onset of the pandemic ( JAMA Network Open ). Between 2019 and today, the number of American adults reporting anxiety and depression has risen from 11 percent to 42 percent ( CDCP Survey ). That means there are over 97 million people, almost half of the American workforce, suffering from anxiety and depression. There is currently no indication of those numbers dropping back to pre-pandemic levels, and experts predict that mental health challenges will be the primary non-virus-related health crisis in the wake of the pandemic.

Business leaders are wisely taking note. Due to a drop in productivity , increased absenteeism, increases in benefit spending, and higher turnover rates, the financial cost of employee mental health challenges is startling. In pre-pandemic years, before the current surge in mental health disorders, mental health conditions cost employers between $100 and $500 billion per year, and 217 million days of lost work, annually, in the United States alone ( NAMIpierce.org ). Worldwide, depression and anxiety typically cost the global economy over US$1 trillion annually due to drops in employee productivity ( World Health Organization ).

Time will tell the full impact of the current mental health crisis on business growth and financial bottom lines, but one thing is clear: if organizational leaders don’t play a proactive role in supporting the mental health of their employees, their organizations, like their people, will suffer. Given that the current surge in mental health needs has outpaced provider availability, there’s an opportunity for business leaders and human resource departments to play an increasingly critical role in maintaining the resilience of their greatest asset: their people.

Being proactive about personnel mental health pays off. Estimates suggest that a $1 investment in mental health leads to a $3-$5 return on investment ( One Mind At Work ). Not only does addressing mental health increase productivity and reduce benefit spending and absenteeism, it ultimately reduces employee turnover, as well, and this is a money saver. Hiring a new employee costs a company an average of 33 percent of the employee’s salary ( Employee Benefit News ). Given that depression doubles an employee’s likelihood of leaving a job ( One Mind At Work ) and that 9 percent of employees cite wellbeing-related concerns as the reason they left their jobs ( Work Institute ), employers wanting to spend less on hiring would do well to invest in mental health support for their current personnel.

How Can Business Leaders Support Mental Health?

While the specific interventions that are feasible may vary depending on the size of your company, I recommend this three-pronged approach regardless of company size: 1) Create a culture of wellness; 2) Foster compassionate leadership practices; and 3) Support employees in accessing direct care that meets their mental health needs.

Create a Culture of Wellness

Creating a culture of wellness starts with understanding mental health needs and prioritizing them. As Unilever’s chief learning officer told HuffPost journalist Tim Munden, "If you want a high-performing company, you need resilient, healthy employees.” Make use of these tried and true facts about mental health in order to create the foundation of a culture of wellness.

• Job satisfaction and longevity go up, as do overall mental health and self-esteem , when we feel engaged in work that feels meaningful and authentically aligned with our values and our aspirations. Help employees foster a sense of purpose and autonomy in their work and career trajectory. Create a collaborative environment where employees can bring their ideas forward, work with colleague mentors, and encourage professional growth and development for others. Offer opportunities for ongoing learning in areas of employee interest. And help employees see how their efforts contribute to the company’s larger goals , values, and impact on the world.
• Time outdoors soothes the central nervous system , reduces anxiety, and leads to the release of “feel-good hormones ” like dopamine and epinephrine that help ward off depression. Consider creating appealing outdoor spaces employees can retreat to for breaks, or even for individual or small group work sessions. If you have enough land, invest in building walking trails; the combination of fresh air, sunlight, and exercise is the mental health Holy Grail. If you’re a small company without land or financial resources or your workforce is working remotely, create an incentive program to get people to go for a local walk during their breaks.
• A healthy work-life balance reduces stress , generates more positive engagement with work, and allows for health-critical sleep. When we are sleep deprived, the amygdala, a part of the brain that regulates mood and emotion , doesn’t function properly and we are vulnerable to both depression and anxiety. Late night work hours, particularly involving screen time , disrupt our natural circadian rhythm by impeding the production of melatonin, our natural sleep aid, and replacing it with adrenaline and cortisol. Assess your cultural norms. Is there an expectation, spoken or unspoken, that the employees respond to texts or emails at all hours? Are people rewarded, implicitly or explicitly, for working extra hours and prioritizing work over family, fun, and sleep? Extra short-term employee productivity may strike employers as a good thing. But maintaining mental health—and the financial and productivity gains that come with it for your company—is a marathon, not a sprint. So set a culture of daily balance whenever possible, and provide adequate vacation time and PTO for balance over the long haul. Finally, assess your own behavior; actions speak louder than words, and the behavior of the leaders sets the tone. Model, from the top down, that balance is valued, rewarded, and considered best practice.
• We benefit from connection over isolation, support over shame , and information over ignorance. Many people fear talking openly about their struggles because they fear being judged, or even professionally punished. When mental health struggles go underground, they escalate, and solutions become much harder to access. Therefore, it’s critical to reduce the stigma around mental health within your organization. Companies, large and small, are learning that talking openly about mental health pays off. Provide workshops and seminars with experts, and create opportunities for people to share their personal stories with each other. Top-down modeling is effective here, as well. When leaders share about their own mental health challenges and successes, employees feel empowered to do the same. We thrive on feeling supported by each other, and on knowing we are not alone. Normalize mental health struggles through programming that creates opportunities to bring personal experiences out of the shadows. The result will be not only be decreased personal suffering, but increased creativity , productivity, longevity, and organizational loyalty. There are highly accessible, creative resources you can make use of to publicly prioritize and de-stigmatize mental health—some are more general, while some focus on specific groups, such as BIPOC employees in the workplace. The options abound, and you can find the resources that fit the needs of your organization, and most importantly, your people.

Compassionate Leadership

While you do not have to become a mental health expert, it is helpful to know how to spot mental health problems so you can support employees who may be struggling. There are some common signs of depression and anxiety that business leaders and managers can learn to recognize. For example, someone with depression will often have a flat or sad mood, or uncharacteristic anger or irritability. You may see decreased productivity and creativity, difficulty making decisions, and memory trouble. A depressed employee may work more slowly, make more errors due to brain fog and reduced executive functioning , and may be less participatory due to social withdrawal and/or a drop in confidence and self-esteem. Due to the biology of depression, you may see someone lose or gain weight, appear sleepy or unmotivated, and even talk or move more slowly than usual. Higher rates of absenteeism may also be a symptom of depression.

While depression may result in an overall sense of someone being slowed down, anxiety may appear to speed them up. When someone is experiencing anxiety, their central nervous system is flooding them with fight-or-flight hormones in response to perceived danger. As a result, you may see physical signs of agitation and tension. However, over time this chronic tension becomes exhausting and impedes sleep, so someone with anxiety may also present with fatigue and irritability. Someone with anxiety will usually be experiencing persistent and excessive worry and a lack of cognitive flexibility, all of which may impede their ability to problem-solve and work efficiently through tasks. Watch for signs of panic attacks, such as shortness of breath and flushed face, and for patterns of avoidance or absenteeism.

Compassionate leadership involves leaning in when you see these danger signs. Respond with care, concern, and curiosity. Encourage open dialogue so your employees can feel seen, accepted, and supported. Avoid punitive responses; employees who are struggling need to be affirmed, not punished or shamed. Strong relationships fuel job satisfaction and longevity as well as mental and emotional health, and those strong relationships start with compassionate, mental health-informed leaders.

To begin your compassionate leadership practice, call yourself to the table to actively listen to your employees, rather than expecting them to uni-directionally listen to you. The transition out of the pandemic shutdown is a perfect opportunity to do this. Listen: do people want to get back in the office? If so, respond by investing in internal infrastructure to promote long-term physical and mental health, such as standing desks, virus control systems, and adequate breaks. Do your employees want to stay remote, or create a new hybrid model? If so, invest in technology to make remote work efficient and sustainable.

Ask what is working and what is not, and expect yourself and your fellow leaders to adapt to the needs you are being shown, rather than expecting employees to not have needs. Problem-solve collaboratively to create concrete solutions and foster a sense of connection and support that boosts mental health and job satisfaction. And remember, women, BIPOC, and Gen Z/millennial employees have been hit the hardest by the pandemic. Proactively check in with them; listen, and respond collaboratively and compassionately to what you hear.

Practicing compassionate leadership involves paying attention to the human experience. Invest in training your management and leadership team in cultural inclusion, active listening, and supportive responding vs. defensive or punitive reacting. Employees respond better to positive communication and a feeling of support (positive drive) than they do to negative communication and a feeling of intimidation (negative drive). Listen to your employees’ professional goals, and the challenges they face in reaching them. Help them clear blocks so that they can be creative, inspired, and successful. A company full of thriving individuals is a company that will be thriving.

Access to Direct Care

Support your personnel by making direct care services available. Again, depending on the size of your company and your available resources, your specific solutions may vary. You can provide health insurance with good mental and behavioral health benefits; you can have an in-house Employee Assistance Program; or you can bring in mental health experts to provide psychoeducation, support groups, and workshops to develop coping skills. If you are low on financial resources to develop programming, you can simply grant employees permission to leave work for mental health appointments without taking PTO. You can also seek out easily accessible, low-cost resources, such as e-courses and educational videos, and offer them to your employees as a health benefit.

Finally, remember that therapy isn’t the only therapeutic direct care. Consider bringing in chair-massage therapists one Friday per month, or offering regular in-house or virtual yoga classes (you may even have an employee who would like to run them!). If you are a large company with space and resources, offer an in-person or virtual exercise class. Smaller companies can create walking and running groups to encourage exercise at no cost to the organization, and this can even be done virtually if your employees are remote.

Tend to Mental Health Today to be Successful Tomorrow

Experts predict that mental health issues will be the primary concern facing businesses moving forward out of the pandemic. Many of the changes spurred by the pandemic are likely here to stay, such as work models that allow for a hybrid of in-person and remote work. While remote work offers new freedom and opportunity, it also comes with its own challenges—Zoom burnout , isolation, and porous work/home boundaries , to name a few. Companies that focus directly on promoting healthy boundaries and good self-care through a culture that values wellness are more likely to thrive. Leaders who take seriously the charge to develop compassionate leadership, who are open to listening and responding to their employees’ needs in order to help them be resilient and successful, will develop more resilient and successful companies. We are entering an era of attention to the company’s greatest resource: its people.

Lindsay Jernigan, Ph.D. , is a psychologist and master therapist who works with women, couples, and teams. She also offers Reboot, e-courses to promote resilience, connection, and self-full living.

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Mental Health in Family Businesses and Business Families: A Systematic Review

Diane arijs.

1 Department of Work and Organization Studies, KU Leuven, 1000 Brussels, Belgium; [email protected]

Anneleen Michiels

2 Research Center for Entrepreneurship and Family Business, Hasselt University, 3500 Hasselt, Belgium

Associated Data

Data sharing not applicable.

Mental health issues in family businesses and business families have been studied in multiple disciplines within the past three decades. This article systematically reviews 51 articles on mental health issues in family businesses and business families, published in a wide variety of psychology, entrepreneurship, and management journals. Based on a systematic review of extant literature, this article first provides an overview of the state of the art, followed by specific suggestions on novel research questions, theoretical frameworks and study design. This way, the review systematizes evidence on known antecedents and consequences of mental health issues in family businesses and business families, but also reveals overlooked and undertheorized drivers and outcomes. The review reveals major gaps in our knowledge that hinder a valid understanding of mental health in the specific context of family businesses and business families, and articulates specific research questions that could be tackled by future research among management as well as mental health scholars. Finally, we point to the relevance of this study for policy makers, family business advisors, therapists and managers.

1. Introduction

Mental health and psychosocial wellbeing were included as an integral part of the United Nations Sustainable Development Goals (SDGs) in 2015 for the first time, thereby recognizing it as a global development priority [ 1 ]. Mental health issues are affecting individuals and families worldwide, but also the businesses they operate in [ 2 ]. This is especially the case for family businesses (hereafter: FB), the most ubiquitous form of organization worldwide [ 3 ]. The intertwining and interdependence of the family and the business system, which is unique and inherent to family businesses, creates both competitive resources as well as challenges and disadvantages for the involved business [ 4 ], their involved families [ 5 ] and their non-family stakeholders [ 6 ]. This intertwining of the family and the business sub-system confronts business families (hereafter: BF) and their advisors with unique challenges when it comes to their psychological and emotional health [ 7 ] with for example spill-over and the risk for aggravation of tensions from one sub-system to another. Mental health issues are thus likely to affect FBs and their owning business families in multiple ways, both positive and negative [ 2 ].

The closely intertwined family and business system in FBs [ 8 , 9 ] results in interactions and exchanges of resources across the family and business system which are crucial for sustaining the FB, especially during times of disruption [ 10 ] such as during the coronavirus disease 2019 (COVID-19) pandemic and its aftermath in which the wellbeing of family and non-family members has been put under pressure [ 11 ].

In this paper we systematically review the literature on drivers and outcomes of mental health issues within family businesses and business families. Literature on this important topic is widely dispersed across various disciplines. Therefore, we are convinced that it is time to take stock of the current literature and to give a broad and complete overview of what we know on mental health issues in family businesses and business families, which will form a good basis to elaborate future studies in this area. For the purpose of this review, we consider articles dealing with “all” types of family businesses, meaning that they can be characterized by family involvement in various ways (e.g., management, ownership or governance), and that they can be small or large; public or private. Similar to [ 12 ], we do not consider single owner-managed firms with no other relatives involved, as family firms.

For the purpose of this review, we employ the World Health Organization (WHO) definition of mental health. This indicates that mental health is “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community”. The important implication of this definition is that mental health is more than the mere absence of mental disorders and disabilities. By employing this definition, we expand the literature review of [ 2 ], who focus on mental disorders of individual relatives in family businesses. Our broader scope of mental health is in line with the paradigm shift in the field of psychology, which traditionally focused on negative aspects of human experiences such as mental disorders and their treatment, towards the emerging field of positive psychology [ 13 ] which focuses on factors that maintain and promote mental health in respect to happiness, engagement, and self-actualization [ 14 , 15 ].

Given that studies on mental health in FB and/or BF are widely dispersed across various disciplines and given the specific challenges that the FB context poses on understanding and managing mental health in FB and BF, we want to contribute to a more integrated understanding of mental health in the FB context. We will do this by taking stock of the literature so far and by pointing to relevant future research areas. Hence, the central aim of this systematic literature review is to draw attention to mental health issues as a research area that could benefit from being positioned more centrally and in a multidisciplinary way in management, family business, psychology and public health literature. To this end, we assess the literature of drivers and outcomes of mental health issues in the family business system (i.e., at the individual-family- and business-level), to provide guidance to policy makers and practitioners and to inspire future research on this topic. The objective of this review is, therefore, to specifically address the following three research questions: what is the current state of the literature on mental health issues in family businesses and business families? (RQ1); what are the implications for future research in this domain? (RQ2); and what are the implications for policy makers, family business advisors, therapists and owners? (RQ3) In an attempt to answer these research questions, we present the state of the art on mental health issues in the context of family businesses and business families. We first identify gaps in the current literature, where we focus on the subtopics that have been addressed, the study context, methods and theories applied. We then articulate avenues for future research in this area, with the aim to advance the knowledge on mental health issues in family businesses as well as business families.

The remainder of this article is structured as follows. In the first section, our review method is presented in detail. Next, we discuss the study selection and present the general characteristics of the studies that were retained for the review. Finally, gaps in literature are identified and potentially fruitful avenues for future research (in terms of relevant research questions, theoretical frameworks, and research methods) are articulated as well as insights and recommendations for policy makers and family business advisors and mental healthcare providers.

2.1. Review Method

For this article, we follow the systematic review method that has been used in previous management research, which is based on the process used in medical science and healthcare [ 16 , 17 ]. This method allows researchers to map and assess the relevant research and to articulate research questions which will advance the knowledge base. A rigorous review method is essential to be able to provide insights and guidance for scholars, as well as for practitioners and policy makers [ 16 ]. In light of the exploratory nature of our research question, the heterogeneity in our data (i.e., studies published in many different disciplines), and the fact that this is a less mature field of research, a systematic review is the most simple and straightforward method as it can point to missing data and call for empirical research at the right point in time [ 18 ]. Essentially, it is our goal to identify a comprehensive sample of journal articles that (empirically or conceptually) discuss mental health issues in family businesses and business families.

The first choice we made, was to only include peer-reviewed journal articles, thereby excluding unpublished work, books and book chapters. This restriction can be expected to enhance quality control as most refereed journals have strict requirements for publication [ 19 ]. The second choice was to use the following databases: ISI Web of Science Core Collection, EBSCO Host Business Source Complete and PubMed. Because these databases search in multiple disciplines at once, they can be considered to be appropriate and efficient for our purposes. The third step was to select a sample of articles from the millions of articles compiled in these databases. Article titles and/or abstracts had to include terms referring to both mental health issues and family businesses. We identified the following keywords to capture the ‘family entity’: “family firm*” OR “family-owned” OR “family-controlled” OR “family-managed” OR “family compan*” OR “family business*”OR “business famil*”. These terms were combined with keywords used to capture the ‘mental health entity’, which, according to our definition employed (mental health as a hybrid of absence of a mental disorder and presence of well-being) includes aspects related to mental health, absence of mental health, or coping: “mental” OR “health” OR “well-being” OR “wellness” OR “self-efficacy” OR “autonom*” OR “self-actuali*” OR “psychological capital” OR “resilien*” OR “disorder” OR “dysle*”OR “autis*” OR “addict*” OR “burnout” OR “stress” OR “strain” OR “coach*” OR “therap*”. We searched for a combination of a mental health entity and a family entity in the title and/or the abstract of articles that were published in print or online until July 2020. This step led to a total of 845 articles being identified through database searching. In order to ensure no relevant research articles were missed, we manually checked major outlets for family business research individually by checking the indexes. Through this step, an additional six articles were identified.

2.2. Articles Selection

For a journal article to be retained in the analyses, we decided it had to either conceptually advance our understanding of mental health issues in family businesses or business families, or to empirically test propositions regarding mental health in a family business or a business family context. Thus, in the next step, the relevance was checked by the two authors who independently read all titles and abstracts. All abstracts that were indicated as ‘irrelevant to the review’ were excluded. Disagreements on article selection were resolved by consensus. Then, all remaining articles were downloaded and the full text was read by both authors independently. Several articles were excluded due to non-compliance with the established inclusion criteria. Examples were: no considerable conceptual or empirical understanding of mental health issues in family businesses or business families, or the use of one of the search terms in a different context (e.g., “…the authors stress the importance of” or “financial well-being ” or “…are engaged in earnings management). In this review, we define a family business as a business where at least two family members are involved in ownership, management or governance. Hence, we exclude studies on single business owners-entrepreneurs with no other relatives involved.

2.3. Data Extraction and Synthesis

After all relevant articles had been selected, both authors independently coded the articles following a predefined coding scheme in Excel. Disagreements on coding were resolved by consensus. The following aspects were coded for each paper: year, author, outlet, mental health topic, focus (family/business/individual), research question, core theoretical concepts or frameworks, research method, sample, variables included (dependent, independent, moderator, mediator), findings related to mental health in the family business or business family.

3.1. Results of Literature Search

A total of 845 papers were obtained through database searching, and an additional six articles were identified through other sources. After removing duplicates, 534 articles remained. After evaluating the titles and abstracts, 456 articles were removed from the sample. Of the 78 full-text articles that were assessed for their eligibility, 51 papers were retained for our final sample. See Figure 1 for a visual representation of our literature search in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram [ 20 ].

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the search and screening.

3.2. Study Characteristics and Synthesis of Results

The first study that was published on mental health issues in family businesses and business families dates from 1989. This indicates that this research field is less mature, but it is also not surprising, since academic interest in family businesses only emerged in the 1980s [ 21 ] and has increased rapidly in the past two decades [ 22 ].

Academic interest in the mental health topic in family businesses and business families has been increasing rapidly with 73% of all papers (38 papers) in our sample being published after 2010. The articles in our review have been published in a variety of disciplines including entrepreneurship, psychology, management and family studies.

The mental health topics that have received most attention in scholarly research are wellbeing, family- and self-efficacy, therapy and resilience. The studies in our sample investigated mental health topics at a variety of levels. For example, resilience was studied from an individual family member perspective (e.g., [ 23 ]), from a family-level perspective (e.g., [ 24 ]), from an organizational, family business, perspective (e.g., [ 25 ]) or from a combination of the aforementioned levels. A wide variety of theoretical frameworks were used to develop hypotheses, with the most frequently used theories being: family systems theory (6 papers), self-determination theory (2 papers), work-family interface (4 papers), sustainable family business theory (2 papers). The research method that was used most often, was quantitative in nature (e.g., regression, structural equation modelling, correlations) (21 papers). Fifteen papers in our sample were conceptual, or theoretical, in nature. Another six papers were primarily based on consulting experiences and often provided fictionalized examples. Only 8 papers used a qualitative research strategy through interviews and/or case studies. When quantitative or qualitative data were analysed from a specific country, they came primarily from the USA (19 papers), followed by China (3 papers) and Austria (2), Belgium (2) and Canada (2).

The theoretical foundations that have been used in our sample come from various disciplines, such as psychology (e.g., self-determination theory, psychological capital); family science (e.g., Bowen’s family systems theory, circumplex model) and management (e.g., resource based view, stewardship theory). There is no theory that stands out in terms of number of times used, as we have identified 41 different theoretical frameworks in our sample. Eleven papers in our sample did not rely on a clear theoretical framework.

Table 1 gives an overview of the literature that has been reviewed in this article. More specifically, we summarized the findings of our sample studies according to their focus on one (or more) of the following aspects of mental functioning in the family business system: mental disorders and syndromes or mental health; and its respective drivers and outcomes, as illustrated in Figure 2 .

Mental health issues researched in family businesses and business families. (Note. Family Business System = Family, Business, Individual.).

Overview of extant research on mental health in family businesses and business families.

4. Discussion and Suggestions for Future Research

The aim of this review was to draw attention to mental health issues as a research area that would benefit from being positioned more centrally and in a more multi-disciplinary way in management, family business, psychology and public health literature. By means of this literature review we thus aim to open up and start a new conversation which might inspire and guide future relevant research and practice for studying and dealing in a more adequate way with mental health in the FB context. Based on our systematic literature review we identified three major gaps in our knowledge that hinder a valid understanding of mental health in the specific context of FB and BF: a lack of understanding of the effect of the business on the family and its family members’ ill-being and well-being (Research Gap 1); a need for adopting a multi-level perspective on mental health in FB (Research Gap 2); and a lack of an open-systems perspective incorporating the environmental level in studies of mental health in FB (Research Gap 3). In this section we formulate fruitful research avenues on the topic of mental health in FB and BF based on these detected gaps and provide a number of sample research questions which could fill in these gaps in our knowledge.

4.1. Research Gaps and Sample Research Questions

By transferring the positive psychology-based view of mental health to the FB context, our literature review also encompasses studies that explored factors, practices and conditions that enabled FB ownership to yield positive effects on individual and familial well-being. So far, most literature focused on the effects of family ownership on business performance and hardly touched upon the effect a business can have on the owning or running family involved in it [ 5 , 45 ] (i.e., first research gap). For the studies that did focus on the impact of the business on the family, the predominant focus was on ill-being of the family (e.g., tensions, quarrels, ruptures) due to the business involvement [ 60 ]. Role conflicts due to dual roles as member of the family and member of the business seem the dominant antecedent of this ill-being in this family business literature stream [ 57 ]. Only few studies investigated the benefits of being involved or having work experience in the family-owned business for individual relatives. The main outcomes point to higher reported parental support and less addiction for adolescents involved in the FB, e.g., [ 39 , 40 ]. Hence, we lack knowledge on how being involved in the family business can affect the mental health (both ill-being and well-being) of individual family members and of the family system.

For studying the effects of the business on the mental health at ‘individual level’ , the self determination theory might be a promising theoretical framework for future research. A FB with clear values and norms supporting FB participation may be a double-edged sword for individual family members to reconcile the need for autonomy (e.g., freedom of career choice) with the need for relatedness (e.g., normative commitment as a drive for joining the FB, [ 71 ]). Tapping into self determination theory literature, some studies suggest that given the social context, individuals may forgo some autonomy needs in exchange for relatedness (e.g., [ 72 ]) as being put forward by [ 31 ] for the FB context. This brings us to two sample research questions:

RQ 1: What are the optimal levels of basic psychological needs to foster psychological well-being of individual family members in the FB context and which practices are effective to reach or restore this optimal interplay?

RQ 2: How can a FB reach an optimal interplay between autonomy and relatedness to ensure psychological well-being of individual family members (e.g., successors)?

For studying the effects of the business on the mental health at ‘family level’ , ‘family self-efficacy’ (e.g., [ 34 ]) might be a promising concept as a theoretical base for future research. In particular, we detected the need for empirical support for its key dimensions and for insights in developmental experiences and tools to cultivate this family self-efficacy. Self-efficacy is an important antecedent of well-being in mental health literature in general [ 73 ]. In a FB context, taking into account the multi-level interplay of mechanisms contributing to mental health (i.e., research gap 2), we stress the importance of studying not only individual family members’ self-efficacy but also collective efficacy among involved family members–family members’ shared beliefs in its family’s capabilities as a group–to ensure the necessary encouragement and support among family members [ 57 ]. The family support was already put forward in entrepreneurial literature as a driver for mental wellbeing of entrepreneurs, often female entrepreneurs (e.g., [ 74 ]). Within FB literature so far the emphasis has been put on the importance of entrepreneurial self-efficacy among successors which might be beneficial for the FB (e.g., [ 75 ]). The sustainable success of a FB depends on both the success of the business system and the family system, i.e., the central tenet of Sustainable Family Business Theory (e.g., [ 24 ]). Therefore, it might be important to gain more insight in how to cultivate and groom domain -specific self-efficacy at individual level (e.g., entrepreneurial self-efficacy), at business level (e.g., industry knowledge) as well as at family level (i.e., family self-efficacy) and in how these all interrelate. The explorative qualitative study of [ 34 ] already mentioned the need of the development of a domain-specific FB self-efficacy scale in 2007. They pointed to important dimensions in this FB self-efficacy scale, such as having the capability and confidence in the competencies to maintain good relationships with the incumbent and other involved family members in the FB, maintain good relationships with other business stakeholders, have business-specific knowledge, but acknowledged that there was no insight in how these skills and confidence in these skills could be fostered in the specific FB context. Based on our systematic literature review, we have to conclude that more than a decade later the literature still falls short in having a valid and reliable FB self-efficacy scale and in having insights in how to develop these domain-specific efficacy dimensions. Hence, useful research questions to focus on might be:

RQ 3a: Which dimensions (i.e., items comprising individual, family and business level) belong to a domain-specific FB self-efficacy scale?

RQ 3b: How can each of these dimensions be cultivated most effectively in the FB context (e.g., role of incumbent, of mentors, of coaching, of training programs)?

Taking into account the need for more multi-level studies in the FB context (i.e., research gap 2), a related research question that deserves our attention is:

RQ 4. To what extent can collective family-efficacy moderate the effect of individual family members’ self-efficacy on the mental wellbeing of individual family members, the family’s well-being and the performance of the business?

In fact, self-efficacy is part of the broader concept of ‘psychological capital’, a central tenet in positive psychology [ 76 ]. Ref. [ 55 ] were the first to introduce the concept of Organizational Psychological Capital, as a potential leading but yet overlooked concept in FB studies. So far, the four dimensions of OCP–organizational hope, optimism, resilience and efficacy have been addressed in mainly conceptual papers in the specific FB context (e.g., [ 59 ]), with a few exceptions that provided empirical testing (e.g., [ 44 ] for effect of family business resiliency on role interference). Hence we need more empirical underpinning of the premises and optimal level of ‘organizational psychological capital’ in a FB context . In addition, there is the need for a distinction in this group-level approach of this construct between family as a group and the organization (comprising of family and non-family employees) as a group. Furthermore, we have only a limited understanding of how each of the four dimensions of this psychological capital can be developed at family and at business/organizational level beyond individual level. For example, the recently introduced concept of ‘family resiliency’ (i.e., family’s belief in their ability to discover solutions to manage challenges, [ 77 ]) in family business literature by e.g., [ 44 ]) as the family’s adjustment strategies and coping capacity to respond to stressful events) is distinct from organizational resiliency [ 25 ]. Family and organizational resiliency can have meaningful interrelations, and can be fostered via other tools in a FB context, nonetheless it is important to assess them each separately to find rigorous relations with outcome variables. This brings us to the challenge of bringing this psychological capital to higher levels with rigorous conceptual and operational definitions [ 78 ]. The FB context might provide a fruitful context to contribute to this multi-level approach with the following sample research questions:

RQ 5a How is each dimension of psychological capital– measured at individual, family and organizational level—affecting individual, family and business outcomes?

RQ 5b Which theoretical mechanisms can guide meaningful cross-level effects?

Previous research has yet demonstrated that psychological capital is trainable (e.g., [ 76 ]). Based on these insights, we formulate the following sample research question:

RQ 5c How can organizational psychological capital be fostered in the specific context of a FB for the family and for the business group-level?

Overall, we notice in our systematic literature review that studying the effect of the business on the involved family is scarce , but slightly on the rise. This valuable future research avenue may further benefit from integrating insights and theories from family science literature (e.g., the Circumplex Model of Family Systems, Family Fundamental Interpersonal Relations Orientation, or FIRO, Theory) [ 5 , 49 ]) to enrich FB literature (e.g., improved insights in how to reach sustainable family business success) and family therapy literature with this unique but omnipresent context of FB among their clients. We notice that there is hardly any empirical evidence on which type of interventions and which type of family business advisors are most effective per type of family business issues and especially business family problems.

Next, none of the studies in our literature review has focused on the environmental level and its interplay with mental health in the family business context (i.e., research gap 3). This gap in literature is a surprise, as yet in 2007 FB scholars explained the need for an open-systems approach as conceptual model to adequately study FB [ 8 ]. The recent COVID-19 pandemic has shown that also FB and their business families are severely hit not only business-wise but also in terms of mental health [ 79 ]. COVID-19 and its aftermath have put considerable strain on the physical and emotional wellbeing of family and non-family members, bringing tensions to the surface (e.g., on dividend pay-outs, on decisions on business model changes or on sticking to tradition), engendering negative emotions (e.g., grief, frustration, anxiety, fear) which might undermine the clarity of thought of key decision-makers in the FB [ 11 ]. Notwithstanding this strain, FBs seem to focus on employee well-being during this crisis [ 79 ]. Individual family members’ sacrifices for securing the continuity of the FB (e.g., missing dividend payouts), seemed to be facilitated if the family benefits from alignment and cohesion, which is enabled by good communication practices. This challenge brings us to the following important research question:

RQ 6: What is the impact of COVID-19 on the wellbeing of family and nonfamily members in the FB?

With regard to the well-being of employees in a FB context in non-crisis situation, we find mixed evidence. For example, results are contradictory on whether employees in FB versus NFB are more or less victim of workplace bullying [ 26 , 28 ]. We believe that more in-depth insight into which mechanisms are at play due to the involved owning family, might help unraveling these conflicting results. We illustrate this with the interaction between generation at helm and seniority of employees: favoritism might prevail towards employees with higher seniority by the founding FB owners while the opposite might occur with succeeding generations taking over the reins leading to power conflicts and triggering mobbing for this high seniority subgroup. Beyond statistical consensus on the well-being of employees in FB versus NFB settings, insight in the mechanisms at play is needed, as it might enable practitioners and policy makers to set up more effective interventions in these different contexts. This also holds for the processes leading to burn-out in a FB context. It was a surprise that the omnipresent topic of burn-out in mental health and occupational health literature is still untouched in the FB context. In the entrepreneurial context, the need for studying entrepreneurial burn-out and its unique antecedents and outcomes is already detected (e.g., [ 80 ]). Also, in the FB context, it is likely that the unfolding of burn-out among involved relatives as well as among non-family employees might be different than in non-FB context due to the higher risk of role conflict. This brings us to the following sample research question:

RQ7 Which antecedents and mechanisms result from the unique involvement of owning families in organizations to affect employee well-being (e.g., bullying, burn-out)?

We want to point to some limitations in our review method. Firstly, we only included published work, which might have prevented us from integrating creative insights which might not have made it to peer-reviewed publication outlets yet. We made this choice to ensure a good quality standard for the studies on which we based our insights in our review. A second limitation has to do with the exclusion of non-English publications. English is the mainstream language for scientific research (on family businesses) so we are confident that the exclusion effect will be limited on the scope of our included studies. We want to add that although U.S. is largely represented in our sampled articles, also other non-English speaking countries were present in our sample like China, Belgium, and Austria. For the time period, we want to emphasize that we did not use a ‘lower limit’ for year of publication and that the most recent year being yet 1989 for mental health in FB is a reflection of the recent nature of the family business field as academic field [ 21 ].

4.2. Relevance to Pracitioners: Family Business Advisors and Healthcare Providers

For practitioners it might be useful to explicitly integrate in the family constitution how resiliency will be developed, and at individual, family and family business level. This attention for the different processes at play in building resilience at the different levels is recently put forward in research (e.g., [ 25 ]). This way, and adequate family-practice fit can be assured [ 81 ]. Such a code of ethics can also avoid deviant behavior of family and non-family employees [ 32 ] and as such avoid tensions.

The omnipresent antecedent of role conflicts impacting the family’s and individuals’ well-being and the FB performance can be prevented or mitigated by open communication which can prevent or reconcile unrealistic (dual) role expectations [ 57 ]. Ref. [ 59 ] found empirical proof for the indirect effect of open communication through a shared vision on the FB on next-generation leadership effectiveness and work engagement, which precludes a better multi-generational survival with respect to a better mental health at work (as work engagement is vital to wellbeing at work according to positive psychology studies, e.g., [ 82 ]). Relying on these empirical findings brings us to the advice for practitioners to invest in family meetings where open communication is facilitated or trained. This training in effective communication and conflict resolution skills can reduce stress and facilitate healthier relationships. We would like to re-emphasize the call of ref. [ 53 ] to also include extended family members in this training and business family communication. Unfortunately, so far research overlooks in-laws for their effect on the mental health of the business family. Therapists can also benefit from the awareness of stress induced by the business family communication dynamics for in-laws [ 53 ]. Therapists or coaches can also benefit from systemic work like the tetralemma for solving problems or dilemmas in business families for example due to the fact that one communicative event might trigger even contradictory reactions in the family and the business system and lead to a seemingly impossible way out to make a ‘right’ decision [ 48 ].

The cultivation and stimulation of collective family-efficacy beyond self-efficacy of individual family members is likely to be fruitful to facilitate multi-generational survival [ 57 ] where the individual relative, the family and the family business can flourish. This entails that a FB advisor is not only able to provide or recommend individual coaching to foster self-efficacy of individual relatives, but also group coaching to the family group to ensure that the belief in the capabilities of the family as a group is shared and the complementarity is embraced which can serve as a prevention or a healing mechanism against rivalry (e.g., among successors).

Lastly, relying on Sustainable Family Business Theory [ 10 ] and on insights from our literature review on therapy and consulting in a FB context, e.g., [ 30 , 35 , 48 , 50 , 69 ], business families need family therapists that are familiar with emotional family dynamics, systemic work, and have affinity with the FB context/literature but equally need business consultants who can focus on business challenges. Who is involved depends on the needs of the FB clients, but an exchange of information, most ideally a collaboration or even an interdisciplinary partnership, between these two streams of advisors might be most beneficial to ensure sustainable family business success.

4.3. Relevance to Policy Makers

Our systematic literature review also brings forward some implications for policy makers. First, it emphasizes the importance of wellbeing strategies for employees in a family business context which take into account the specific nature and challenges of the family business context. Proactive and reactive policies to foster or restore employees’ mental health in family businesses should be aware of the risk of poor communication among business families that spills over to the business and creates stress for non-family employees (e.g., [ 68 ]).

Given the interplay at three levels for understanding and intervening adequately in the mental health challenges of family business systems, e.g., [ 25 ], we formulate the suggestion for policy makers to create certified programmes for FB advisors that should focus on fostering expertise relating to mental health at all three levels (i.e., individual, family and business) of the family business system. In addition, FB advisors should be made aware of the need to team up with experts in other domains (e.g., family therapists, communication experts) if their knowledge is insufficient for dealing adequately with specific mental health needs at e.g., the family level to build or restore for example family-level efficacy or family-level resiliency. In addition, it might be worth policy makers considering a requirement for a code of conduct or a code of ethics for the discipline of family business advisors. In this code this multi-disciplinary expertise could be central, or at least the deontological duty for teaming up with other experts of other disciplines to adequately deal with mental health needs at all levels of the family business system. In this way policy makers can support and require family business advisors to develop interventions that have the potential to result in sustainable success, hence at all three levels (individual-family and business) and preferably in an integrated way across all three levels.

The inheritance systems of FB legacies have an undeniable influence on sibling rivalry, stress and entrepreneurial spirit (e.g., [ 70 ]). Policy makers should, therefore, carefully consider the impact of inheritance policy measures not only on economic development, but equally on family and individual well-being, when (re-)designing business succession or inheritance schemes.

5. Conclusions

In this systematic review, we focused on mental health issues in family businesses and business families. The main incentive for this systematic literature review is the increasing importance of this topic, as well as the multidisciplinary nature of studies in this domain. Literature on this topic is quite fragmented, which restricts scholars’ capacity to effectively integrate the insights into a more comprehensively developed perspective. Developing a state of the art on mental health issues in family businesses and business families allows us, therefore, to structure extant evidence, which enables us to provide relevant findings for practitioners and policy makers and to identify gaps and discuss interesting new research directions which can guide future research in this domain. Overall, we can conclude that the uniqueness of family businesses, being the intertwining of the family and the business system, represents a double-edged sword for business families that strive for mental health at individual, family and business levels. Based on our systematic review of the literature, we identified three major gaps in our knowledge, that hinder a thorough understanding of mental health issues in the specific context of FB and BF: (1) future research might benefit from studying further the impact of being together in a business on the business family. More precisely, more insight is needed in how the well-being of the business family and its individual members can be supported by, for example, exploring tools and testing its effects empirically for building resiliency and domain-specific efficacy at individual, family and business levels. (2) In addition to this multi-level focus, also the interplay between the different levels, i.e., systems, is highly relevant if we want to build a further valid theory on mental health in the family business context (3). Lastly, the environmental level is currently a blind spot in how mental health is studied in a family business context. Our study translates our current knowledge on mental health in the FB context in concrete implications for policy makers, practitioners (advisors and healthcare providers) and researchers.

Author Contributions

Conceptualization, A.M. and D.A.; methodology, A.M. and D.A.; analysis, A.M. and D.A.; writing—original draft preparation, A.M. and D.A.; writing—review and editing, A.M. and D.A.; visualization, A.M. and D.A. Both authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

McDonough Professor Catherine Tinsley Appointed to Kate Spade New York’s Social Impact Board to Address Women Empowerment, Mental Health

Maria Camila Gutierrez

March 8, 2022

Kate Spade New York recently launched a new Social Impact Council , comprising several leading women’s empowerment and mental health leaders from around the globe, to further their mission of enhancing women and girls’ mental health through social impact work. Among the list of founding women includes Georgetown McDonough’s professor and director, Catherine Tinsley. 

Tinsley is the Raffini Family Professor of Management, faculty director of the Georgetown University Women’s Leadership Institute , academic director of Georgetown McDonough’s Executive Master’s in Leadership program, and a senior policy scholar at the Georgetown Center for Business and Public Policy . As an expert on gender intelligent leadership and gender parity, she has dedicated her career to research and initiatives focused on empowering women leaders. 

The women serving on Kate Spade New York’s leadership council will each bring their unique expertise to help address mental health stigma, provide access to resources, and bring more attention to the vital role that mental health plays in the empowerment of women and girls globally. The council will partner with the brand to meet its goal of reaching 100,000 women with direct access to mental health and empowerment tools by 2025.

“Everybody matters, but more importantly, everybody needs to believe that they matter – that they are valuable and can make a difference,” said Tinsley. “Programs that address mental health and well-being are leverage multipliers because empowered participants are able to then return back the dividends of this empowerment to their families and communities.”

Kate Spade New York’s social impact initiatives originated with its on purpose label in 2014, a fully integrated commercial division of the company where women in Masoro, Rwanda, are empowered to make high-quality products for Kate Spade’s brand through a local handbag production facility, Abahizi Rwanda. Tinsley was among three Georgetown McDonough School of Business professors who conducted research on the initiative to understand the viability of the unique value chain approach, while also studying the psychological, social, and economic impact on the women and communities in Masaro. 

Tinsley’s research identified a direct correlation between the employment experience in Masaro and higher levels of physical health, social standing, power, and confidence – increasing their social standing and creating a more empowered workforce of women in rural African communities. This research has been the basis for Kate Spade New York’s ongoing efforts to champion initiatives that target social outcomes and improve mental health in an impactful and sustainable way for women across the globe.

“Women’s empowerment has been at the heart of our social impact efforts for over a decade, and has become a core pillar of the Kate Spade New York brand,” shared Liz Fraser, Kate Spade New York chief executive officer and brand president. “The foundational role that mental health plays in a woman’s life and in women’s empowerment has only become more clear through our social impact work. Mental health has long been undervalued, under-acknowledged, and underfunded. And yet it is of more concern today than ever.”

Kate Spade New York continues to further its role as an advocate for mental health by using its platforms to raise awareness, while working to de-stigmatize the topic. The brand and its Foundation plan to donate more than $2M annually to provide access to care and community resources to improve the mental health and empowerment of women in its communities around the world.

To view all of the social impact work happening at Kate Spade New York and to read more about Tinsley’s involvement with the Social Impact Council, visit katespade.com/socialimpact .

Daria Nepriakhina via unsplash.com

Addressing Depression During Adolescence ‘Critical’ To Avoid Issues in Young Adulthood

New research has articulated the stakes of addressing youth mental health issues as early as possible.

Depressive symptoms in adolescence are at historic highs and are enduring into young adulthood, according to a new study by researchers at Columbia University and the University of Michigan. Those born between 1997 and 2001 had the highest rates of depressive symptoms at ages 18, 19 to 20, and 21 to 22 years among all birth cohorts for both males and females.

The prevalence of depressive symptoms in females declined with age but remained at a historically high level. For males, rates of depressive symptoms increased at age 22. Those born between 1997 and 2001 are the most recent birth cohort examined in the study . 

“The findings of this cohort study suggest that the current increase in depressive symptoms among U.S. adolescents is swiftly shifting to an increase in young adult depressive symptoms as adolescents move into adulthood,” the study states. “Given this persistence, reducing the onset of depressive symptoms through primary prevention and mental health resources during the adolescent years is critical.”

Researchers examined longitudinal data from annual surveys conducted from 1990 to 2019. The birth years of roughly 37,000 respondents spanned from 1972 to 2001.

Specifically, about 19% of female respondents born from 1997 to 2001 had high depressive symptoms at age 18. That rate dropped to 12% by ages 21 to 22 years. For male respondents, about 13% had high depressive symptoms and showed an increase to about 16% for the same ages.

Compared to those born from 1972 to 1976, females born from 1997 to 2001 had about seven times higher odds of having high depressive symptoms, while males had about six times higher odds of having high depressive symptoms at ages 21 to 22.

“Population attributable fractions indicated that the total proportion of young adult symptoms associated with depressive symptoms at age 18 years among females has increased; in the most recent birth cohort, 55.25% of depressive symptoms at age 21 to 22 years were associated with symptoms at age 18 years,” the study reads.

However, the study did find that the relationship between depressive symptoms enduring into youth adulthood did not differ between the birth cohorts. In part, rates are higher later for the most recent birth cohort because their levels were high at age 18, demonstrating the worsening of youth mental health in recent years.

These data illustrate the need that several youth mental health-focused companies are seeking to address. In recent years, a flood of venture-backed telehealth or telehealth-enabled startups have joined more established, traditional behavioral health providers in the effort. 

Some of the fastest-growing companies in the U.S. are behavioral health providers working with students in K-12 and post-secondary settings. These include telehealth providers Uwill and TimelyCare. 

Most recently, BeMe Health landed a $12.5 million funding round from a single investor in anticipation of a formal Series A. 

Headway founder Jake Sussman founded Marble earlier in the year to provide teens with in-network therapy. The company has raised $5 million in seed funding from venture capital firms, including Khosla Ventures, Town Hall Ventures and Daybreak Ventures. Backpack Health, formerly Youme Healthcare, raised $14 million in Series A funding in May. 

Talkspace (Nasdaq: TALK), one of the largest digital mental health providers in the U.S., has a growing book of business with local municipalities like cities and school districts to provide care to young people. 

Chris Larson

Chris Larson is a reporter for Behavioral Health Business. He holds a bachelor's degree in communications from Brigham Young University and has been covering the health care sector since December 2016. He is based in the Louisville metro area. When not at work, he enjoys spending time with his wife and two kids, cooking/baking and reading sci-fi and fantasy novels.

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‘nobody is going to fight getting a child treated’: payers more open to covering tms, how addiction providers are integrating services for co-occurring conditions.

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Navigating Mental Health at Work: A Reading List

• HBR Editors

Resources for employees, managers, and leaders.

Simone Biles’s withdrawal from Olympics competition has reignited a global conversation about mental health and work. Here’s some resources for those struggling with mental health at work, as well as managers who want to prepare for these these conversations with employees.

As the latest in a series of high-achieving public figures who has taken a step back from work to focus on their mental health, Simone Biles has reignited an ongoing conversation about mental health, disclosure, and stigma.

But public figures are not alone: More and more people are talking to their bosses about their mental health. Surveys show employees want to work at a company whose culture supports mental health ; in fact, it’s becoming one of the most-requested benefits in the wake of the pandemic . This is especially true for young workers: In a recent Deloitte survey of more than 27,000 Millennials and GenZers around the world, nearly half ranked mental health as their first or second priority.

As a manager, how can you prepare yourself for these conversations with your employees? Or better yet, what can you do if you’re the one personally struggling with mental health at work? Here are some resources to help.

For Individuals

We Need to Talk About Mental Health at Work

In the U.S. one in four adults struggle with it. (November 2018)

What Covid-19 Has Done to Our Well-Being in 12 Charts

The pandemic has led to mental health declines, increased work demands, and feelings of loneliness. But the news isn’t all bad. (February 2021)

Make Mental Health Your #1 Priority

In a global survey, 48% of Gen Zs said they feel anxious most of the time. (September 2020)

Your Mental Health and Your Work (podcast)

At a time when we bring so much of ourselves to work, mental health is still something we don’t like talking about at the office. But so many high-achieving people have suffered — or are currently suffering — from anxiety, depression, or other mental and emotional issues. (September 2019)

When You Need to Take Time Off for Mental Health Reasons

And how to get back into the swing of things afterward. (March 2018)

For Managers

Research: People Want Their Employers to Talk About Mental Health

Nearly 60% of employees have never discussed their mental health at work. (October 2019)

When Your Employee Discloses a Mental Health Condition

Best practices for navigating the conversation. (February 2021)

Talking About Mental Health with Your Employees — Without Overstepping

Three tips. (November 2020)

Eight Ways Managers Can Support Employees’ Mental Health

Nearly 42% of employees report a decline in mental health since the pandemic began. (August 2020)

Five Ways Bosses Can Reduce the Stigma of Mental Health at Work

One in four adults struggle with a mental health issue. (February 2019)

• This story is by the staff at Harvard Business Review.

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School Milestones Impact Child Mental Health in Taiwan

This study uses administrative health insurance records in Taiwan to examine changes in child mental health treatment around four school milestones including: Primary and middle school entry, high stakes testing for high school, and high stakes testing for college entry. Leveraging age cutoffs for school entry in Taiwan, we compare August-born children to children born in September of the same year. The former hit all the milestones one year earlier than the latter, enabling us to identify each milestone’s effect. We find that entry into both primary school and middle schools is associated with increases in mental health prescribing, not only for ADHD but also for depression. Middle school entry is also associated with increases in the prescribing of anti-anxiety and antipsychotic medications. Perhaps surprisingly, there is no run-up in the use of psychiatric medications prior to high-stakes tests. But the use of psychiatric medications falls sharply following the tests. These effects are stronger in counties where both parents and children have higher educational aspirations. Hence, the use of psychiatric drugs increases at junctures when educational stresses increase and falls when these stresses are relieved.

We thank the Health and Welfare Data Science Center and the Ministry of Health and Welfare in Taiwan for access to data and we thank Ming-Jen Lin and seminar participants at Princeton and Fudan Universities for helpful comments. Gustav Chung Yang and NTU C2L2 lab provided excellent research assistance. Chen acknowledges the support from the National Science and Technology Council grant NSTC 111-2628-H-002-019 and the Yushan Fellow Program by the Ministry of Education, Taiwan (MOE-112-YSFSL-0003-001-P1). Currie thanks the NOMIS Foundation for their support. Any errors are our own. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

MARC RIS BibTeΧ

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• Find Your Calm: Managing Stress & Anxiety

Stress Symptoms

What Is Stress?

Stress is your body's response to a challenging or demanding situation. When you feel stressed, your body releases certain hormones. Your hormones are chemical signals your body uses to tell your body systems what to do. The hormones your body releases when you're stressed get you ready to meet the challenge or demand in your environment. During the stress response, your body gets ready to flee or fight by increasing your heart rate, breathing rate, and blood pressure.

Not all stress is bad. In small doses, stress can help you accomplish tasks or prevent you from getting hurt. For example, stress is what makes you slam on the brakes to avoid hitting a suddenly stopped car in front of you. That's a good thing.

But people handle stressful situations differently. What stresses you out may be of little concern to someone else. 

Stress can be a short-term response to something that happens once or only a few times or a long-term response to something that keeps happening. Our bodies can usually handle short-term stress without long-term effects. But long-term or chronic stress can make you sick, both mentally and physically.

The first step to managing your stress is to know the symptoms. But recognizing stress symptoms may be harder than you think. Many of us are so used to feeling stressed that we may not know it until we get sick. Read on to learn more about the various symptoms you may have when you're stressed.

Difference between stress and distress

Stress is a normal reaction to challenges in your physical environment or in your perceptions of what's happening around you. Experts consider distress to be stress that is severe, prolonged, or both. Distress is when you feel you’re under more stress than you can handle.

Emotional Stress Symptoms

Mental symptoms of emotional stress include:

• Feeling more emotional than usual, especially feeling grumpy, teary, or angry
• Feeling anxious, overwhelmed, nervous, or on edge
• Feeling sad or depressed
• Feeling restless
• Trouble keeping track of or remembering things
• Trouble getting your work done, solving problems, making decisions, or concentrating 

Physical Stress Symptoms

Symptoms of stress that you might feel in your body include:

• Clenching your jaw and grinding your teeth
• Shoulder, neck, or back pain; general body aches, pains, and tense muscles
• Chest pain, increased heart rate, heaviness in your chest
• Shortness of breath
• Feeling more tired than usual (fatigue)
• Sleeping more or less than usual
• Upset stomach , including diarrhea , constipation , and nausea
• Loss of sexual desire and/or ability
• Getting sick more easily, such as getting colds and infections often

Respiratory distress

This is when you aren't getting enough oxygen or are having to work really hard to breathe. If you or a loved one has symptoms of respiratory distress, you need to call 911 and get to the ER as soon as possible. Signs include:

• Breathing faster than usual
• Color changes of your skin, mouth, lips, or fingernails. A blue color around your mouth, lips, or fingernails usually shows you aren't getting enough oxygen. Your skin may also look pale or gray.
• Grunting when you breath out
• A whistling with each breath (wheezing)
• Nose flaring
• Chest sinking below your neck or under your breastbone with each breath (retractions)
• Increased sweating, especially cold, clammy skin on your forehead
• Leaning forward while sitting to help take deeper breaths

Cognitive Stress Symptoms

Symptoms of stress that affect your mental performance include:

• Trouble getting your work done, solving problems, making decisions, or concentrating
• Feeling less commitment to your work
• Lack of motivation
• Negative thinking

Behavioral Stress Symptoms

Symptoms of behavioral stress include:

• Changes in your eating habits; losing or gaining weight
• Procrastinating and avoiding responsibilities
• Using alcohol, tobacco, or drugs to feel better
• Avoiding your friends and family; isolating yourself from others
• Failing to meet your deadlines
• Increased absences at school or work
• Doing your work more slowly
• Exercising less often

Symptoms of Chronic Stress

Chronic stress is when you experience stress over an extended time. This can have negative effects on your body and your mental state, and it can increase your risk of cardiovascular disease, anxiety, and depression.

In general, the symptoms of chronic stress are the same as those for shorter-term stress. You may not have all these symptoms, but if you have more than three symptoms and they last for a few weeks, you may have chronic stress. Potential symptoms to look for include:

• Aches and pains
• Changes in your sleeping patterns, such as insomnia or sleepiness
• Changes in your social behavior, such as avoiding other people
• Changes in your emotional response to others
• Emotional withdrawal
• Low energy, fatigue
• Unfocused or cloudy thinking
• Changes in your appetite
• Increased alcohol or drug use
• Getting sick more often than usual

Is It Stress or Something Else?

You may be dealing with something more serious than day-to-day stress if you have symptoms over a period of time even though you've tried to cope using healthy mechanisms. Long-term stress is linked to number of mental health disorders, such as:

• Chronic stress
• Substance use disorder
• Disordered eating

It may be time to visit your doctor if you're struggling to cope with the stress in your life or you have mental health problems from long-term stress. They can help you figure out ways of coping in a healthy way or refer you to a mental health professional who can help you.

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is mental health condition that you may have after you have or witness a traumatic event, such as a natural disaster, accident, or violence. PTSD overwhelms your ability to cope with new stress. PTSD can lead to symptoms such as intrusive memories, avoidance behaviors, and hyperarousal. 

These symptoms can cause significant problems in your work or relationships. T alk to your doctor or a mental health professional if you've had or witnessed a traumatic event and have disturbing thoughts and feelings about it for more than a month, if your thoughts and feelings are severe, or if you feel like you're having trouble getting your life back on track.

What Are the Consequences of Long-Term Stress?

Ongoing, chronic stress can trigger or worsen many serious health problems, including:

• Mental health problems, such as depression, anxiety, and personality disorders
• Cardiovascular disease, including heart disease , high blood pressure, abnormal heart rhythms, heart attacks, and strokes
• Obesity and other eating disorders
• Menstrual problems
• Sexual dysfunction, such as impotence and premature ejaculation in men and loss of sexual desire in men and women
• Skin and hair problems , such as acne, psoriasis, and eczema, and permanent hair loss
• Gastrointestinal problems, such as GERD, gastritis , ulcerative colitis, and irritable bowel syndrome

Help Is Available for Stress

Stress is a part of life. What matters most is how you handle it. The best thing you can do to prevent stress overload and the health consequences that come with it is to know your stress symptoms.

If you or a loved one is feeling overwhelmed by stress, talk to your doctor. Many symptoms of stress can also be signs of other health problems. Your doctor can evaluate your symptoms and rule out other conditions. If stress is to blame, your doctor can recommend a therapist or counselor to help you better handle your stress.

Stress Takeaways

Stress is your body's response to a challenging or demanding situation. It can affect you physically, mentally, and behaviorally, especially when you have chronic stress. Chronic stress is when you are stressed for an extended time. Chronic stress can make it more likely for you to develop other mental health disorders, such as anxiety or depression. It can also affect your heart health and digestive health. If you're stressed and having trouble coping, it may be time for you to see your doctor or a mental health professional.

Stress FAQs

What can extreme stress cause?

Extreme stress, especially if it's prolonged, can cause emotional distress. And stress from a traumatic event, which is usually extreme, can cause posttraumatic stress disorder (PTSD). These are more serious cases of stress that overwhelm your ability to manage on your own. You may need to get a professional's help to get back on track. If you feel like you're having trouble managing your emotions, talk to your doctor. They can help you or direct you to someone who can help you.

Can stress make you throw up?

Yes, stress can make you throw up. Your digestive system is one of the many systems that stress can affect. In fact, you may have a whole range of other digestive symptoms, such as nausea, pain, and constipation or diarrhea. Not everyone has stress nausea or vomiting, but you may be more prone to it if you have a gastrointestinal condition, such as irritable bowel syndrome (IBS), or you have anxiety or depression.

You may be able to tell if you're stress vomiting if your episode passes when the stress goes away. If it doesn't, then your episode may be caused by something else. It's time to get checked out by your doctor if you have more than a couple of episodes or you can't figure out what's causing them.

Show Sources

Chu, B. Physiology, Stress Reaction , StatPearls Publishing, 2024.

American Psychological Association: "Stress effects on the body."

MedlinePlus: "Stress."

Mayo Clinic: "Stress management," "Emotional exhaustion: When your feelings feel overwhelming," "Post-traumatic stress disorder (PTSD)."

Cleveland Clinic: "Emotional Stress: Warning Signs, Management, When to Get Help," "Stress Nausea: Why It Happens and How To Deal. "

Johns Hopkins Medicine: "Signs of Respiratory Distress."

Helpguide.org: "Stress Symptoms, Signs, and Causes," "Understanding Stress."

Yale Medicine: "Chronic Stress."

Department of Health and Human Services: "Stress and Your Health."

American Institute of Stress: "Effects of Stress."

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Heart-Pounding, Stomach-Knotting: Stress and You

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More From Forbes

Prioritizing mental health when you’re on a budget.

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There are a number of ways to prioritize your mental health when finances are a barrier to accessing ... [+] therapy.

Earlier this month, LifeStance Health , one of the largest providers of virtual and in-person outpatient mental healthcare services in the United States, released findings from a new survey of 1,085 U.S. adults that explored Americans’ mental health, their ability to access mental health support, and how therapy ranks in their overall household budgets, among other issues related to mental health.

70% of survey respondents reported that they experienced stress, worry, anxiety, or depression. Among those currently experiencing mental health challenges, 64% had previously sought therapy. Over half (54%) ranked therapy or similar mental health services as their top discretionary expense priority.

If given the option, half (50%) stated they would choose a year of free therapy sessions over opportunities like free Taylor Swift concert tickets, free Super Bowl tickets, or an all-expenses-paid luxury cruise.

65% of respondents shared that they would be unable to afford therapy if it wasn’t covered by their health insurance plan. However, reflecting the fact that having health insurance doesn’t always guarantee that someone will be able to find the mental health care that they need, while 66% were able to find a therapist who accepts their insurance and has availability, 27% of those surveyed had not been able to.

If you're struggling to fit therapy into your budget, you're not alone.

Best High-Yield Savings Accounts Of 2024

Best 5% interest savings accounts of 2024, why therapy is hard to afford.

Joy Liu is a Certified Financial Trainer at the Financial Gym based in Wilmington, North Carolina. “As many people live paycheck-to-paycheck, it can be hard to work any big expense into their budget.”

She adds that for those with an existing mental health challenge, “it can be hard to prioritize accordingly” if executive functioning is impacted by their condition, and the process of finding a therapist—much less one who takes their insurance—can be overwhelming. “There are a lot of hoops to jump through, unfortunately.” Online searches, finding out if they need a referral, making phone calls or reaching out via email, following up...it can become a frustrating process.

The cost of therapy can also be a barrier for many, and that cost can vary depending on factors such as the location where the therapist is based, the amount and type of training the therapist has, length of the session, and the therapist’s specialization. The cost of a session can range from as low as $65 to an hour, to as high as $250 or even higher. Insurance co-pays can vary but average from $20-$50.

Theodora Blanchfield, AMFT , a Los Angeles-based therapist, says, “Therapy can be incredibly expensive! I know so many fellow therapists who can't even afford to see their own therapist. And if you are somehow lucky enough to find a therapist who does take insurance and is taking on new clients, it still might be months before you are able to see them.”

Blanchfield recommends seeking an out-of-network therapist who will provide you a super-bill so that you can submit to your insurance for partial reimbursement. “What clients don't know when they're looking for therapy is that many therapists do not take insurance because reimbursement rates for therapists can be incredibly low and take a ton of time and work on top of the usual session. By not taking insurance, we are able to take on more clients and help more people.”

How to make —and stick to—a budget that includes therapy

“Step number one,” says Liu, “is to understand the difference between a fixed expense budget and a variable budget.” Fixed expenses are things like rent or mortgage payments, car payments, and utilities. The cost of variable expenses change.

Once you are clear on what those are in your life, Liu explains, “you can start to compartmentalize and commit. Once all the fixed expenses are built into your income, that gives you an idea of what’s left for variable expenses and what you can save.” Knowing what you need to budget in each category can help you get a handle on what is available for therapy and what trade-offs you may need to make in order to make it fit into your budget more comfortably.

Of course, having a budget and sticking to a budget are two different things. When it comes to helping yourself be consistent with healthy money habits, Liu encourages automating as much as you can. “One thing we encourage for our clients, along with separating fixed from variable expenses, is committing to all the things important to you, including savings goals, as things that automatically happen to make it as clear as possible for you to see how much you have left over for variable expenses.”

That might look like having your paycheck automatically be split between a few accounts—for example, a checking account and a savings account, or if you’re married, perhaps a joint account along with a personal and a savings account). Liu adds that because there are so many different payment options (cash, credit card, debit card, payment apps and more), she encourages separating out what you use to pay for fixed and variable expenses to make it easier to keep track of what money you have available. She encourages tracking spending as closely as possible by using a system that works for you. “For example,” she says, “maybe you have one account where all fixed purchases are paid from and then you have an account for variable expenses.”

Reducing therapy costs

In addition to exploring online therapy platforms, which have become increasingly popular for their accessibility in terms of cost and time commitment, there are some lower-cost therapy resources that Blanchfield recommends for those who can’t access in-network care and for whom out-of-network coverage is insufficient. “Open Path Therapy Collective is a nationwide collective where member therapists offer sessions at between $40-70 each to clients, and it’s a great way to find lower-cost therapy. Additionally, you can see if colleges or universities near you have a counseling center where their therapists in training see clients at a lower fee. Another option is to search for associate or pre-licensed therapists in your area—often their rates will be lower than a fully-licensed therapist.”

She adds, “If you are part of a marginalized group, groups like The Loveland Foundation or Lotus Therapy Fund offer scholarships. Finally, if you find a therapist whom you like but you can't afford their posted rate, it's always worth asking if they have sliding scale spots—or if they know someone who does.”

She also suggests exploring group therapy. “One of my favorite things to say about therapy is that it is a microcosm of the ‘real world’ outside the therapy room. What I mean by that is that if you're someone who has trouble speaking up to your therapist, you're likely someone who has trouble speaking up in other areas of your life, too. For this reason, I think group therapy can be an awesome lower-cost therapy option, if you're not coming to therapy to process a specific issue or trauma. In group therapy, you often talk through the dynamics that are showing up in real-time in the room with other people—not just your therapist. You'll end up learning a lot more about yourself and how you operate in the world—and how you can feel more comfortable doing so—than you'd expect.”

One thing Liu adds is that sometimes, therapy is absolutely medically necessary but the funds just aren’t there. “When it comes to health, including our mental health, sometimes it doesn’t matter if we have money. If you’re making a conscious choice and know that nothing else will work until you get your mental health sorted out, it’s okay to put finances on the back burner for now. There are many ways to measure how you make decisions. Money is just one of them.”

If that is the case, she recommends making a plan for how to pay off debt you may need to accrue to cover mental health care and also exploring resources like getting financial support from your community, Church, or a charitable organization.

Getting the most out of therapy

Once you’ve found the right way to make therapy a part of your routine, you want to make sure you’re optimizing the time, energy, and money invested.

“One of the best ways someone can get the most out of their therapy experience is to journal immediately afterwards,” says Blanchfield. “What was that session like for you? Did it feel like a huge relief to get that off your chest and you feel lighter now? Or did you really get deep into something and you're feeling drained? What do you want to take away from it and implement into your life and how will you do that? This can be either a new way of thinking about something or trying a new coping skill such as a thought log, where you write down as many of your negative automatic thoughts as you can catch.”

Equally as important as actually writing these notes, she adds, is actually returning to them later in the week so you can reflect on what you wrote.

Prioritizing mental health

Therapy can be a crucial tool for managing mental health, but the financial barriers can often feel overwhelming. However, with thoughtful budgeting, exploring lower-cost options and making small changes to your spending habits, therapy can be incorporated into your routine. Seeking out sliding-scale therapists, using online mental health platforms and leveraging community resources are a few ways to access the care you need. Remember, investing in your mental health is one of the most important commitments you can make to yourself. By making mental health a priority, you’re caring for your mind while also setting yourself up for long-term well-being and resilience.

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Springfield, MO

Opinion: Group therapy can improve mental health care access

As the stigma around seeking mental health care continues to decrease, our needs have increased in recent years here in the Ozarks and across the U.S., and the demand is leading therapists nationwide to experience longer backlogs. Fortunately, there are many ways to receive immediate care and connect with a professional if you’re in crisis, whether it’s by calling or texting 988 or by seeking care at community behavioral crisis centers.  

We also want people to receive care as soon as possible before they reach a crisis state. To do that, clients and clinicians alike need to continue to expand their definitions of what top-quality therapy looks like. And a growing body of research shows that it looks like group therapy. 

If you, a loved one, a close friend or a co-worker ever find yourself in need of professional counseling and are presented with a longer than desired wait time to receive one-on-one care, I encourage you to ask your health care providers if there are group treatment options available, if they don’t tell you about those opportunities first. The more comfortable our communities become with small-group treatment settings, with which there is more immediate access to care and the possibility of more individuals healed, the sooner we will see fewer access to care issues locally and nationally.  

Group therapy has been around for decades, but if I asked you to close your eyes and picture a therapy session, odds are you’d envision it the way therapy is most often presented in popular culture – a therapist with a notepad, a client on a couch. Yes, individual therapy often looks something like that, and invaluable healing happens in one-on-one sessions. However, therapy effectiveness occurs by way of more than one method of administration. Research published in the American Journal of Psychotherapy shows group sessions can be just as effective as one-on-one therapy to treat depression, anxiety, trauma, eating disorders, personality disorders, PTSD, chronic pain, substance use disorders and many other conditions people often seek help to address.  

Both in and outside of the behavioral health industry, there have been some long-held stigmas about group therapy being a lesser form of treatment than one-on-one. Those views are fortunately falling by the wayside as data tells us a different story. Brigham Young University Department of Psychology’s Gary Burlingame, a longtime group therapy researcher, led a meta-analysis of 46 randomized clinical trials in 2016, and found that there was “zero difference between individual and group therapy across multiple disorders,” according to the American Psychological Association.  

Additionally, the group dynamic can offer someone going through a traumatic experience reassurance through a key healing element they may not find the same way in a one-on-one setting – the discovery that they are not alone in their suffering. At a time when the U.S. Surgeon General is raising alarms about the epidemic of loneliness and isolationism, spending dedicated time addressing collective issues in a group of confidants can be transformative and therapeutic for someone who thinks their challenges are unique to them.  

Most therapy is still conducted in a one-on-one setting in the U.S., including at a rate of about 95% to 5% in private practice. In the aftermath of the pandemic, as record numbers of people across all social and age demographics sought professional help, about seven out 10 psychologists said their wait times had grown longer, according to the APA. If just 10% of our country’s unmet needs were met in group settings, here is how big that impact would be, according to a 2023 study published in the APA Journal:  

• About 3.3 million more Americans would receive mental health treatment 
• The need to train and add more therapists to the workforce – we’re currently at about a 34,500 deficit of providers – would be significantly reduced 
• A savings of roughly $5.6 billion in mental health care costs would be realized, in part because of getting people care earlier in the process of seeking it 

Group therapy advocates refer to it as a “Triple E” treatment, because it’s efficient, it’s effective and it’s equivalent, meaning it offers the same type of results you are going to receive in an individual setting. We as mental health providers need to continue driving this message home to people seeking treatment, and we need to continue to ramp up our offerings of group therapy. And if you or a loved one are presented with an option of receiving group treatment sooner than you can access one-on-one care, please know the research shows you aren’t settling for less.  

Dr. Brandan Gremminger has been a licensed psychologist in Missouri for over 10 years and a member of the Burrell Behavioral Health team since 2017, most recently in the role of executive vice president of clinical operations. He can be reached at [email protected] .

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