Over the past several decades, mental health has become an increasingly popular topic in public discourse, fuelled in part by our increased understanding of the many ways it affects all levels of society. When people experience changes to their mental health, their family members – always at the “front lines” – are typically the first ones to feel the effects. Family is society’s most adaptable institution. Families respond by adjusting to meet the needs of their members as best they can. In light of this, a growing number of organizations have offered assistance to employees and their families through Employee and Family Assistance Programs (EFAPs) to manage mental health in the workplace. By looking at the evolution of these services, we can learn how and why the “F” in EFAP first emerged, and how it has grown in importance over time.
The early years: Occupational Alcoholism Programs (OAPs)
Occupational Alcoholism Programs (OAPs) were first introduced in Canada in the late 1950s. Predecessors of the EFAPs, they were focused primarily on alcohol and the devastating impact alcohol has on the health and well-being of employees who experience dependency. These programs were typically delivered through the occupational health and medical departments of large industrial organizations in the manufacturing sector.
Employees would sometimes seek out these services through their own initiative, but more often than not were assisted or referred by their manager, supervisor or union steward. The focus of assistance was almost solely on the individual and the alcohol, and did not include the family. The dependent employee would be put on a strict program that included attending Alcoholics Anonymous meetings, and their compliance would be closely monitored. If the individual relapsed after this treatment, it would usually lead to termination and no further support was provided by the employer. Their future would then depend solely on what level of support their family members could muster – if they were still around.
The formative years: Employee Assistance Programs (EAPs)
During the 1970s and mid-1980s, employers expanded the scope of these programs beyond alcohol, and they became known as Employee Assistance Programs (EAPs). Previous research on occupational productivity had shown that alcohol dependency was just one of many issues that could have an impact on a person’s performance, productivity and health in the workplace.
Although alcohol addiction was still seen as a problem, it became increasingly clear that workplace programs could benefit from including support for other issues that can affect productivity, such as other addictions, mental illness, serious health conditions or major life events such as births and deaths. More employers began to understand the value of offering EAPs and, as a result, mid-size, regional, national and global companies introduced programs in their organizations.
EAPs would typically offer short-term, solution-focused counselling, paid for by the employer, with either an average number of sessions or a predetermined maximum number of sessions allotted. EAPs were never intended to provide longer-term care, but when that was necessary, the provider would make a referral to an affordable and appropriate resource. EAPs were increasingly managed by human resources (HR) instead of occupational health and safety or medical departments.
During their prime working years, many people face concerns about their mental health, which EFAPs can help them to manage. Studies have shown that mental health conditions are not only costly to individuals, but also to the organizations to which they belong:
• Depression will rank second only to heart disease as the leading cause of disability worldwide by the year 2020.
• Disability represents anywhere from 4% to 12% of payroll costs in Canada; mental health claims (especially depression) have overtaken cardiovascular disease as the fastest-growing category of disability costs in Canada.
Some employers also started to understand the importance of families in the equation of employee attendance, concentration and focus. Emotional distress, family/personal relationships, child care, eldercare and health care started to get employers’ attention. Many began reaching out directly to family members at home to increase awareness and usage, and to help mitigate the negative impacts of these issues on performance and productivity. Communication materials were specifically designed for spouses and dependants, and creative methods were used to reach out to family members. Program admission was further expanded to include eligible young adults and family members who were attending post-secondary education institutions.
At first, utilization of these programs and services by families remained low, prompting further attempts to increase awareness and usage. One of the factors that limited their use was the fear that personal information would be shared with a counsellor or EAP practitioner and have consequences for the employee at work. Although EAP services were confidential (and remain so), the concerns about confidentiality and privacy protection understandably impaired users from taking advantage of services. During this period, 5% to 7% of the employee population accessed EAP services on any given year, with less than 1% attributed to family members.
While the first generation of EAPs was delivered by internal staff (usually MDs and occupational health nurses), this new generation of programs was typically outsourced to external firms that provided a broader range of professionals and specialty practitioners, including psychologists, counsellors and other health providers. This contributed to broadening the legitimacy of EAPs; however, these programs were still being offered primarily by larger companies and therefore were not yet mainstream. As a result, those who did not work for these firms were typically underserved.
The growth years: Employee and Family Assistance Programs (EFAPs)
The late 1980s through the mid-1990s were marked with important progress in this field. First, EAPs started providing an ever-expanding array of services, including responses for addictions, family/marital relations and psycho-emotional issues. These “broadbrushed” EAPs also recognized the importance of providing services for work relationship issues, financial, legal, aging parent and other non-work-related concerns. With this expansion in scope, EAPs began to take greater hold across a broad range of industries, sectors and workplaces.
Over time, a growing body of research demonstrated that investments by employers in EAPs resulted in various cost benefits, including reduced absenteeism, lower turnover, fewer medical costs and overall higher employee productivity. With this data, EAP providers were able to engage an increasing number of employers of various sizes in other industries to implement an EAP. The level of acceptance grew considerably and, with it, thousands of families and individuals gained access to resources and care.
Providers began offering toll-free 24/7 access to counsellors to eliminate barriers to reaching assistance if and when it was needed. Increased efforts to reach out to the homes of employees did increase family member utilization; however, in most programs, dependant use averaged 5% to 10% of the total utilization. Attention was also now being given to prevention and health promotion through the provision of resource materials, workshops and seminars. Stress management workshops were a central part of the education efforts, with the goal of giving participants the knowledge and tools to remain healthy and productive at work. EAPs also expanded to include services related to dealing with conflict in the workplace, managing workloads realistically and communicating effectively.
Current EFAP Referral Patterns: Percentage of Calls Received, by Issue
45% Marital and family problems
25% Psychological (depression, anxiety, self-image)
15% Work-related problems
10% Substance abuse/alcohol abuse
5% Personal trauma/crisis
Another major step during this phase was the rebranding of Employee Assistance Programs to Employee and Family Assistance Programs (EFAPs). Although most programs had already included the family, this formal change explicitly identified the family as a key stakeholder in the provision of services. Credit needs to be given to the stewards of the MacMillan Bloedel EFAP for having the wisdom and vision to be this apparent and inclusive. They were the first to coin this term, which has become the standard reference for these types of services in Canada. This simple insertion spurred on greater interest in program enhancements for the family into the next phase of evolution.
The maturing years: Today’s EFAPs
From the mid-1990s to today, EFAPs have grown in popularity to the extent that most large and mid-size employers offer some form of program. Even smaller employers (i.e. fewer than 50 employees) have started to offer programs through group plans or community initiatives. This has been largely due to the partnerships that have developed between EFAP providers and group insurance providers in which the group plan can include the EFAP as another option for employers to offer. A range of counselling models (assessment and referral, short-term counselling, etc.) surfaced, varying depending on the organizational culture, industry and program in question. Employers had more models to choose from. During this phase, a wider range of services was made available by telephone, face to face or, more recently, online.
Online services increased accessibility, as they could be reached outside of the workplace from mobile devices and personal computers. This mode of access has increased the use by family members, and future expansion is expected. Online resources such as educational modules on parenting, communicating emotion, enriching relationships and dealing with aging parents are all now common offerings and can be accessed at home or on the road.
Prevention and health promotion has recently expanded to include wellness. A growing number of employers are assisting employees (and their families) to take charge of their overall health, including emotional, psychological and physical well-being. Health risk appraisals (HRAs) have become increasingly available; individuals can benchmark their current health risks and learn how to reduce those risks. Many employers are taking a holistic approach to employee health and wellness, and they are recognizing the importance of the family unit in maintaining and enhancing healthy choices and decisions. Overall employee health is increasingly seen as a vital part of an organization’s “bottom line” thanks to a growing body of research demonstrating direct links between employee well-being and rates of engagement, absenteeism and productivity.
Costs of Mental Illness in the Workplace
- In any given week, more than 500,000 Canadians are absent from work because of mental illness.
- More than 30% of disability claims and 70% of disability costs are attributed to mental illness.
- Approximately $51 billion each year are lost to the Canadian economy because of mental illness.
Current and emerging legal requirements are now compelling greater numbers of employers to ensure that their workplaces are psychologically safe and built on relationships of civility and respect. In 2013, the federal guidelines for the National Standard of Canada for Psychological Health and Safety in the Workplace were introduced to help organizations actively work toward creating psychologically healthy and safe environments for employees.
This standard was developed using evidence-based research from a variety of scientific and legal disciplines; it outlines existing knowledge on the psychological health and safety of workers, and provides guidelines and recommendations for promoting and maintaining healthy workspaces. While the standard is voluntary, there is still an obligation for employers to provide some degree of care based on current and evolving legislation and case law. As Dr. Martin Shain, who has written extensively on psychological safety in the workplace, says, “A psychologically safe workplace is no longer a nice to do, but is now a must do.”
The future of EFAPs
In the early days, when services focused on alcoholism, employers could readily fire an employee for non-compliance. In today’s climate, whether in response to legislation or regulations, or in compliance with voluntary standards, more employers are providing access to professional assistance and treatment to address the myriad of mental and physical conditions that may disable or impair an employee. After an employee reaches out seeking treatment, employers are taking greater steps to accommodate his or her return to work. As the dialogue on the reduction of stigma surrounding these issues grows in volume and intensity, more workers, families and communities are getting assistance.
The evolution of EFAPs demonstrates a growing interest within organizations to integrate care for the employees, ensuring that family circumstances are considered and enabled. Whether the result of legal obligation or efforts to increase performance and productivity, or out of care for employee well-being, a growing number of employers now take psychological health and safety in the workplace seriously. As interest and investment in EFAPs and employee well-being grows, further breakthroughs are bound to occur. Although it is difficult to anticipate with great accuracy what the future of employee assistance may look like, families will most likely remain a central component of future approaches.
Craig Thompson, MEd, MBA, has been a clinician, business developer, account manager and business leader in the field of EFAP and Disability Management for nearly three decades. Over this period, he has worked with thousands of employers and employees and their families with a purpose of improving their lives and enhancing workplace effectiveness.