Trauma at work: the shocking truth

Published in Healthcare Manager, Autumn 2019. Photo: Stefano Pollio/Unsplash

SPECIAL REPORT: In a disturbing new trend, a small but growing number of NHS managers are being diagnosed with workplace PTSD. Craig Ryan spoke to three MiP members who have paid a high price for the NHS’s failure to tackle toxic workplace bullying.

After months of bullying and extreme pressure at work, and following another traumatic meeting with her boss, Laurie, a senior manager with an NHS system body, broke down on her way home. “It was Christmas and I remember seeing the lights in the city centre,” she recalls. “I was crying and crying on the train and I tried to read a book so people couldn’t see how much I was crying. I don’t remember walking home at all.” 

Laurie was soon suffering from suicidal thoughts and “horrible dreams” in which senior managers were trying to hang her. Her GP and a psychiatrist eventually diagnosed her with Post Traumatic Stress Disorder (PTSD), and she is now on a waiting list for therapy. 

“Getting up for work would be almost impossible at the moment, so it’s really limited my life,” she explains. “I take anti-anxiety medication and anti-depressants, and I’m under a psychiatrist as well. The anti-anxiety tablets have calmed me down an awful lot, otherwise I wouldn’t even be able to have this conversation.”

Laurie believes her condition may be related to an extremely traumatic experience during her teenage years, which she disclosed to her occupational health department. Although they agreed with her PTSD diagnosis, Laurie’s employer provided no support and did nothing to tackle the bullying that brought it on. 

“Almost anything stresses me now. I clam up and freeze very easily,” she explains. “PTSD strips away trust and it becomes scary—I mean, imagine not being able to trust your own family. And dealing with a lack of trust is emotionally, and therefore physically, very tiring.”

Many readers will be horrified—even incredulous—that PTSD, a condition associated with military veterans, victims of natural disasters and witnesses to horrific events, has become an occupational hazard in the NHS. Can you really get shell shock, as PTSD used to be known, just by doing your job as a healthcare manager?

Sadly, yes. Although PTSD is traditionally defined as originating in a single traumatic event, mental health practitioners in Europe and America now recognise that the same symptoms can result from continuous exposure to very stressful situations, such as serious bullying and verbal, emotional or sexual abuse. The term ‘Complex PTSD’ (cPTSD) is increasingly used to describe this condition, and is recognised as a variant of PTSD by the support charity PTSD UK.

The symptoms of cPTSD and conventional PTSD are identical: flashbacks, nightmares, panic attacks, high anxiety, severe depression and suicidal thoughts—often accompanied by alcoholism or drug abuse. Both are psychiatric injuries which can be treated and are not related to personality disorders. 

Workplace PTSD (or cPTSD) is caused by prolonged exposure to extremely stressful situations such as bullying, abuse or harassment. Common factors in the cases known to MiP include:

  • Serious bullying by a manager or series of managers, extending over months or years, and often including gaslighting or mobbing
  • Inexplicable and sometimes bizarre behaviour by managers, which is tolerated or even encouraged within the organisation
  • Employers ignoring occupational health reports and independent medical diagnoses
  • Individuals being kept in the dark about allegations against them
  • Lack of support following previous traumatic experiences at work
  • Victimisation and blaming managers for issues outside their control 
  • Treating mental illness as a performance management issue or character flaw
  • HR and senior management backing the bully rather than the victim

MiP is aware of about a dozen members who have been diagnosed with workplace-induced PTSD. Most of them are women, reflecting the well-established finding that PTSD is more likely to affect women than men. Laurie is one of three women who agreed to share their experiences with Healthcare Manager on condition of strict anonymity. They have all been fully supported by MiP but, to protect their identities, we cannot reveal details of the support they received. 

Like many PTSD sufferers, senior nurse manager Giselle began to drink more heavily to numb her symptoms as they developed. Her doctors believe she contracted PTSD as a result of her employer failing to deal with the psychological impact of a serious patient safety incident many years earlier, and subsequent blatant bullying from a series of managers. Giselle’s condition became so severe, she was only stopped from taking her own life by police intervention.

“The PTSD diagnosis was suggested by the [cognitive behavioural] therapist and my GP, and a psychologist confirmed it,” Giselle explains. “Three times I’ve had trauma at work and then I go into this cycle of mental health deterioration… and then in the end it becomes a disaster, and I reach a crisis point.

Rather than accept responsibility, Giselle’s employer used her symptoms against her and ignored advice from occupational health. “The trust completely said this was about my behaviour; that it’s not about mental health, it’s a character flaw,” she says.

MiP national officer Ruth Smith, who has dealt with a number of workplace PTSD cases, says employers have been slow to recognise the condition and rarely offer the right support. “Even when they acknowledge that someone is suffering from a mental health condition, there’s an expectation it will be a ‘normal’ condition like anxiety or depression,” she explains. “The fact is that counselling and occupational health support just isn’t enough to shift PTSD.” 

In rare cases where PTSD-specific therapies—such as eye-movement desensitising reprocessing (EMDR)—have been tried, they’ve met with “considerable success,” she adds.

Ruth believes the PTSD cases known to MiP represent the thin end of the wedge. “What happened to many of these women—being bullied out of the job—is actually very common now, but we can’t often report it because people just leave and sign non-disclosure agreements,” she says. “These people have reacted psychologically very badly to something that is going on quite widely. Other people might suffer from stress and anxiety instead.”

She stresses that employers have a responsibility to take action and cannot just expect people to cope. “Too often, employers are not willing to make the reasonable adjustments needed for people with serious psychiatric injuries to return to work,” she warns. “That just puts pressure on people who are already vulnerable. Some of our members have suffered one breakdown after another because their employer has failed to take action despite knowing that they have a serious mental illness.”

Clinical manager Steph has undergone bullying and gaslighting behaviour from a senior colleague for more than 12 years. This includes spreading and encouraging false rumours about her, deliberately exaggerating problems and even making a false and malicious complaint to Steph’s professional regulator.

“She flatly just lies—that’s her usual way of operating,” says Steph. “But even when you know she’s lying, it does make you doubt yourself… I did get my line manager and a board member involved, but nobody did anything about it—they were all just pussy-footing around her.

“She was furious that I’d been to [the board member] and she came over to the office and was screaming in my face,” Steph adds. “I thought she was going to hit me.” 

Steph also experienced group bullying or ’mobbing’ at the hands of other colleagues, many of whom seemed to have been intimidated by the same manager. “I ended up in a situation where this really close clique of people were judging my every word and move,” she recalls. “It was like they were saying, ‘you’re nothing here, this is our world’. I heard them talking about other people in the same way. It was like a gang culture—an all for one and one for all kind of thing.” 

Even after occupational health had accepted she was suffering from a mental health condition as a result of previous traumatic experiences at work, Giselle was repeatedly bullied by her then chief executive, and later by her line manager, a member of the trust board. 

“I started to get micromanaged, I started to get bullied, I started to get humiliated,” she recalls. Like Steph, she feels other colleagues were intimidated into joining in. “It was almost like classic childhood bullying. You’re being bullied at school, so you become unpopular and everyone just migrates over there because it’s safer. People were thinking, ‘If it can happen to Giselle, it can happen to anyone’.” 

She found occupational health (OH)sympathetic but ultimately powerless. ”The therapists they referred me to suggested PTSD, but the trust wouldn’t engage,” says Giselle. “We asked them why they didn’t use the OH report but they just said, ‘We didn’t think it was relevant’. I mean, how could it not be relevant?… I was made to feel like I was lying, that I was making it up about having mental health issues to cover up my alcoholism.” 

No one involved with Giselle’s investigation had any knowledge of mental health issues. “One HR manager admitted that he’d made up his own diagnosis about me, even though he wasn’t qualified to make a diagnosis about anything,” she recalls.

Laurie had a similar experience. “OH recognised my condition and recommended a stress risk assessment,” she explains. “At a meeting, my manager actually had the report in his hand, but just ignored it and carried on… repeating all these allegations for which he had no evidence whatsoever.”

As she describes it, Laurie’s ordeal resembles a Kafkaesque nightmare, in which she was kept in the dark about allegations against her and left in state of confusion by her employer’s increasingly bizarre behaviour.

“They kept sending me letters that conflicted with each other,” she recalls. “One letter would conflict with the last letter, or the letter would conflict with itself, and still there was no information about what I’d done wrong, so I was utterly confused by it all.

“I thought at some point they were going to stop because it was just crazy, but it felt like they’d let it get so out of control they didn’t have a way out of it themselves. I had a schedule of allegations which my MiP rep said didn’t amount to anything—they either had no evidence or were really minor. One them was a complaint that I’d opened a window at a meeting!”

MiP’s Ruth Smith says bizarre behaviour by employers is a common feature of the most serious bullying cases. She describes one case in which a member was inexplicably threatened with performance management measures shortly after returning from maternity leave. 

“It was a high-performing service which fell apart when our member was away, because managers refused to backfill her post,” Ruth explains. “They had nine months of disaster, but within a few weeks they were putting pressure on her, asking why the department hadn’t come back into line.

“Managers suddenly started questioning whether she was too young to be in a senior post and making sexist comments about her appearance,” Ruth continues. “Our member was never told what she’d done wrong, and just couldn’t understand why this was happening to her. They were desperately trying to make out it was an issue with her performance, when there’d never been one previously.” 

These three cases fit a disturbing pattern MiP has observed in dozens of bullying cases across the NHS: evidence from the employee, their GP, therapists and even the organisation’s own occupational health services is ignored, while unsubstantiated allegations, trivial complaints and even rumours are taken seriously and used as the basis for aggressive disciplinary or capability action.

“When someone has suffered a psychiatric injury at work, it’s often a result of the way they’ve been treated by the management team,” explains Ruth. “And then we get this defensiveness on the part of the organisation. They close ranks and go to great lengths to protect the bully. And we know that this person will do it again. It’s about power. The bully is often someone who everyone is afraid to stand up against.”

Employers often seem to get locked into a cycle of defending the indefensible for fear of incurring legal liabilities, she adds. “It becomes easier to just dismiss the person who’s being bullied than to continue having them in the workplace. The amount of public money that goes on all the processes, disciplining people and fighting cases, is ridiculous.” 

The real tragedy is that the serious mental illness inflicted on these women—and the other members MiP has supported—were not just the result of the inevitable pressures of working for the NHS. They were caused by the failure of particular employers to tackle bullying at work, or to take seriously the mental health problems it can cause. For that to happen in the NHS—which more than any other employer ought to understand mental health—is a nothing short of a national disgrace.

  • The names of the MiP members participating in this story have been changed to protect their identity. To read more about MiP’s campaign against bullying in the NHS, visit the MiP website.

All in the mind

Published in Public Service Magazine, Spring 2018.

Last year’s Stevenson-Farmer report set out an ambitious agenda for improving mental health and wellbeing in the civil service. Craig Ryan explores the deep culture changes needed to make sure all civil servants can thrive at work.

In January 1974, at the height of the three-day week crisis, the head of the civil service, Sir William Armstrong, suffered a stress-induced mental breakdown. According to several accounts, Armstrong was found naked on the floor of the Downing Street waiting room, chain smoking and raving about the end of the world. The following morning he convened a meeting of his Permanent Secretary colleagues and harangued them about preparing for Armageddon. Armstrong was admitted to hospital, but was back at work within a few weeks. Three months later, he left the civil service and became chairman of Midland Bank.

Armstrong’s breakdown was hushed up and the lessons ignored. Although colleagues later said the warning signs had been there for years, Armstrong received no support and never talked about his problems. The impact of severe stress and overworking on his ability to advise the Prime Minister at a crucial juncture in Britain’s history was never considered. And the effect on Armstrong’s own health – he died just a few years later – was perhaps greater than he knew.

On the surface, the contrast with today’s civil service couldn’t be greater. Government Chief People Officer Rupert McNeil has spoken openly about his problems with anxiety and encouraged colleagues to do the same. Departments have health and wellbeing champions, and have rolled out a plethora of mental health initiatives in recent years, including mental health first aider training, expanded employee assistance programmes and networks where staff get together to talk about workplace problems and the impact on their mental wellbeing.

When Lord Dennis Stevenson and MIND chief executive Paul Farmer published their independent review of workplace mental health, Thriving at Work, in October last year, the government not only accepted all the recommendations as an employer, but designated the civil service as an ‘early adopter’ of the mental health standards laid down in the report (see box). It was, and was intended to be, a clear signal that the civil service is now taking mental health seriously.

But it still has a lot to get serious about. The Stevenson-Farmer report says the scale of the mental health challenge in Britain’s workplaces is “greater than we thought”, and the civil service is no exception. According to MIND’s Workplace Wellbeing Index, public sector workers experience poorer mental health than those in the private sector, with one in six describing their mental health as “poor” and 53% saying they regularly feel anxious at work. Research by Deloitte’s puts the cost of mental health problems to the government at around £1,500 per civil servant every year – again, higher than the average for private sector employees. 

Duncan is a senior manager with a large civil service agency who has suffered from stress-induced anxiety and depression for several years. Two years ago, he was signed off sick after visiting his GP. “I realised quite suddenly that I couldn’t cope, but the problems had been building up for a long time,” he says. “My workload was ridiculous – but so was everyone else’s. There’s this enormous pressure to be busy and to be just about coping, so I just tried deal with it. But I wasn’t sleeping properly, I was drinking a lot and things were starting to fall apart at home.”

Although Duncan’s manager was “not unsympathetic”, Duncan didn’t feel confident discussing his mental health. “I felt I couldn’t cross that threshold, admit I had a real problem. You don’t want to open up that whole can of worms – with capability reviews and assessments by [occupational health]. I was worried about my PMR, my reputation, I was worried about being made redundant – everything really.”

“Working in the civil service is demanding,” says Faye McGuinness, head of workplace wellbeing at MIND, who works with the civil service leadership on implementing the findings of the report. She cites long working hours, regular inspections, lack of interaction with colleagues, and cuts to budgets and staffing as factors that can put pressure on the mental health of all public sector workers. 

“The onus should be on employers to support their staff through the difficult times, so they can come to work at their best, and in turn get the best outcomes for the people they represent – which is why implementing the recommendations [of the report] is so important,” says McGuinness.

Work across Whitehall is being lead by Jonathan Jones, the Ministry of Justice Permanent Secretary who is also the civil service health and wellbeing champion, with support from the Civil Service Employment Policy (CSEP) unit in the Cabinet Office and wellbeing champions in each department.

Jones tells PSM that he has “identified strategic priorities to change the culture towards health and wellbeing in the civil service… These include emphasising visible leadership, enabling honest and open conversations about mental health and encouraging an all-round healthy lifestyle.”

Work is already underway in 18 departments to benchmark existing programmes against the standards set in Thriving at Work . The report identified areas of existing good practice and those where collective improvement was needed, Jones explains, “including how we communicate our offer on mental health to employees, how we continue to build line manager skill and confidence, and how we consistently support people with mental health conditions within the recruitment process.” 

The newly rebranded Ministry of Housing, Communities and Local Government (MHCLG) is widely recognised in Whitehall for being ahead of the curve on supporting workforce mental health. “When I joined the department in 2016, what really struck me was the openness within the [health and wellbeing] network, but also more broadly to talking about mental health issues,” says Jillian Kay, the ministry’s health and wellbeing champion. 

“There were events going on where people were sharing their own lived experiences quite comfortably and openly, and similarly people sharing their own experiences online,” she recalls. “So I sensed that in terms of breaking the stigma it’s certainly a place where lots of people felt safe to share their stories, which felt like a really positive thing.” 

In 2015, The department introduced mental health first aid training and a mental health ambassador listening and support service. MHCLG now has 150 trained mental health first aiders and has a thriving health and wellbeing staff network, and last year was it chosen to design and deliver the mental health awareness workshop at Civil Service Live.

Kay emphasises that the engagement of senior managers is crucial to shifting the workplace culture towards improving mental health. “I was a bit surprised to see members of the SCS on the mental health first aid training when I joined, but actually we’ve now trained 12 SCS members,” she says. “More than 40 first aiders have gone on to become mental health ambassadors, and they provide a listening and advice service to people who need it, including line managers who want to support their staff.” The ministry also runs specialised wellbeing workshops for senior leaders, including one recently facilitated by FDA national officer Jane Cockram. 

Staff resilience and good mental health is very much a live issue for Kay as a manager. In her ‘day job’, she leads for the department on Grenfell recovery and resilience. “Some of our teams have been working with Kensington and Chelsea Council on support for all those affected by the fire. So I’ve get a set of staff who’ve had to be quite resilient over the last year,” she says.

“It really brings home the point that we’re trying to get across in the civil service that we all have good and bad mental health at different times depending on what we’re experiencing. An important part of this is making sure that mental health isn’t a kind of niche agenda, it’s something that’s relevant to everyone – and it became really relevant to all of us over the last year.”

At the same time, the civil service needs to identify and meet the needs of staff who are at a higher risk of developing mental health problems because of the nature of their work, which may include “mainstream” civil servants like Jillian Kay’s MHCLG staff, as well as more obvious candidates like people working for the security services or the National Crime Agency. 

“Departments are being supported centrally to identify teams where there may be a higher risk of stress and trauma, [and] to in turn identify tools and best practice to help all departments address these issues,” explains Jonathan Jones. “Because the support may vary according to the types of work, it’s right that departments lead this work as they’re closer to the detail.” 

One of the persistent themes in the Stevenson-Farmer report is the need for employers to move away from the traditional ‘performance management’ approach, where mental health problems – if they were discussed at all – were tackled as issues of individual capability. This lead to a ‘culture of silence’, where employees kept quiet about mental health problems for fear of demotion, reprimand – or worse.

Instead, says McGuinness, employers need “to create a culture where staff feel able to talk openly about stress and mental health, and know that if they do, they’ll be be met with support and understanding rather than stigma and discrimination.”

This also means managers taking some responsibility for the mental wellbeing of their staff, something that is reflected in one of the Stevenson-Farmer’s most striking recommendations: that civil service leaders should have the mental wellbeing of their staff enshrined in their performance objectives.

“It’s important that Permanent Secretaries and Chief Executives lead by example, and consider how they can be held accountable for the wellbeing of their staff,” says McGuinness. “Having performance objectives relating to employee mental health is one way they can do this… Showing staff that employee mental health is a key priority, and one that they are willing to be measured against, is a step towards creating a positive culture where… staff feel able to talk about their mental health problems.” 

This would certainly be a unprecedented step, with big potential to drive meaningful change. “It’s difficult for us to talk about how this would be implemented as this is based on how they manage this internally. We don’t yet have any other examples of this being done before,” adds McGuinness.

Since returning to work, Duncan says he has benefited from some adjustments to his workload and from taking part in a staff wellbeing network. “Colleagues have been much more supportive than I expected and [management] have been willing to make some changes, which have definitely helped me,” he says. But he still fears his career has suffered, and doesn’t feel confident about pursuing promotion opportunities in the near future. “I still feel there’s this bit of a stigma hanging over me,” he adds. 

Duncan still doubts many of his colleagues would be willing to discuss mental health problems openly with senior managers. “Maybe more managers are willing to have that kind of [supportive] conversation now, but I don’t think it’s enough to change the way people feel,” he says.

Whitehall has come a long way since Sir Robert Armstrong was reduced to rolling around on the Downing Street floor, and mental health problems are being discussed in a way that would have been unthinkable a generation ago. MIND’s Faye McGuinness, who has monthly meetings with civil service leaders to monitor progress, says: “We know there is a long way to go, and that change doesn’t happen overnight. But it’s positive that Government, and in turn, civil service employers, have accepted all the recommendations from the review and see the value in implementing them.” 

For Duncan, the big challenge is ending the culture of silence around mental health, and that takes time: “In the end, it’s not about what support programmes there are, but whether people have trust and confidence to use them. I don’t think we’re quite there yet,” he says.

Stevenson-Farmer: key recommendations for the civil service

  • Permanent secretaries and agency chief executives to have performance objectives relating to employee mental health
  • Commitments to mental health standards to be written into Single Departmental Plans
  • Routine monitoring of employee mental health
  • Enhanced mental health training for staff at all grades, especially for line managers
  • Employers to identify staff and higher risk of stress or trauma and develop a national framework of support
  • Tailored in-house mental health support with signposting to clinical support
  • Encourage open conversations about mental health and the support available to staff