Summary of the impact

This case study describes the impact generated by Dr Paul Flaxman's research in the Department of Psychology at City University London. Flaxman has taken a prominent role in designing a psychological skills training programme that is based on recent developments in the field of psychotherapy. The training has been adopted and utilised by a range of organisations, including Northumbria Healthcare Trust; Central Manchester Foundation Trust; Camden and Islington NHS Foundation Trust; and the South London and Maudsley Mental Health Trust. Other beneficiaries include the City and Hackney branch of Mind (the mental health charity) and nurse training providers at Middlesex University. International reach is evidenced by the adoption of the training for supporting psychiatric nurses working in Uganda. Data collected from over 600 British employees indicate that the training leads to significant and sustained improvements in people's mental health. The training has been shown to be particularly beneficial for employees experiencing a common mental health problem such as anxiety or depression.

Underpinning research

Background
There is a recognised need for effective and efficient interventions that can be shown to improve mental health in workplace settings. Recent estimates suggest that around one in six British workers are experiencing a mental health problem (mainly anxiety and depression) at any one time. Over the past ten years, the theory and practice of cognitive behavioural therapy (CBT) has expanded to include various mindfulness and acceptance-based approaches and there has been growing interest in applying these newer therapeutic approaches to help improve mental health in the workplace.

One of this new generation of psychological therapies is known as acceptance and commitment therapy (ACT). It has been particularly effective when translated into psychological skills training programmes and delivered in the workplace. A member of City University London's Psychology Department, Dr Paul Flaxman, has played a prominent role in these developments. In particular, he has extensive experience of using ACT interventions in workplace settings and of evaluating the impact on employees' mental health. The research underpinning this case study originates from Flaxman's research that was completed while he was a PhD student at City between 1999 and 2003. He was appointed as a permanent member of City's academic staff in 2006.

Flaxman's ACT research programme comprises several longitudinal workplace intervention projects including a series of intervention studies conducted in two local authorities in London, Ealing and Newham, between 2002 and 2004. A second group of studies was conducted at a central government department and three NHS trusts between 2008 and 2010. A third project saw this psychological skills training delivered to around 150 employees of a mental health NHS trust (South London and Maudsley) between 2011 and 2013.The most recent funded project maximises research impact through the transfer of Flaxman's expertise to a group of non-academic partners spread across the UK (2012 to 2013).

Key research insights

The following insights were generated by the originating research:

• ACT-based training in the workplace leads to significant and sustained improvements in mental health for a majority of employees with a common mental health problem (such as anxiety or depression)
• ACT-based training results in improvements in employees' mental health that are equivalent to the effects of more traditional workplace interventions
• ACT-based training delivered in the workplace was found to operate via the same psychological mechanisms as ACT interventions delivered in clinical settings (providing empirical support for translating this therapeutic approach into a workplace training programme).

The peer-reviewed journal articles cited in the next section report the first (and so far the only) studies to compare an ACT intervention directly with a more traditional worksite stress management approach; and the first to demonstrate that ACT can offer clinically meaningful improvements to employees experiencing impairments due to a common mental health problem.

References to the research

(Behaviour Research and Therapy is a peer-reviewed journal and is ranked 15^th out of 354 by SJR in the area of Psychiatry and Mental Health).

(Journal of Occupational Health Psychology is currently ranked 8^th out of 126 journals in the field of applied psychology).

(New Harbinger is the leading American publisher for books on acceptance and commitment therapy.)

Grants:

1. ESRC Research Grant (RES-061-25-0232) awarded to Flaxman — Poor Psychological Detachment from Work During Leisure Time: Antecedents, Implications for Employee Well-Being, and Intervention Effects. Start date: 5^th January 2009. End date: 30^th June 2010. Value: £82,411.74.

Note. Upon completion of this ESRC-funded work, the end of award and impact reports received an overall `Very Good' rating, with one anonymous reviewer evaluating the work as `Outstanding', indicating that...... "the project's achievements are fully commensurate with the level of the award, approach and subject area, and that it has addressed its major objectives with evidence of substantial impact on policy and practice" (ESRC end of award letter, March 2012).

2. ESRC Follow-On Grant (ES/J020575/1) awarded to Flaxman — Delivering contemporary CBT interventions to unemployed and working populations — Start date 1^st November 2012. End date July 2013 (9 months). Value: £23,080.

Note. This more recent ESRC grant was awarded to help maximise the impact of Flaxman's earlier ACT research through a series of `train-the-trainer' initiatives involving non-academic occupational health and vocational rehabilitation partner organisations (described in the next section).

3. Research grant from Guy's & St Thomas' Charity. Flaxman was co-applicant on this grant (conducted in collaboration with South London & Maudsley NHS Trust) — Mindfulness-Based Training to Promote the Well-Being and Resilience of NHS Staff. Start date: August 2011. End date: February 2013. Value: £100,000 (£20,000 secured for City University London to cover Flaxman's time on the project).

Details of the impact

Impact on mental health service providers
As a direct result of Flaxman's funded work, ACT-based training has now been adopted by the staff support services at four NHS organisations: Northumbria Healthcare Trust; Central Manchester Foundation Trust; Camden & Islington NHS Foundation Trust; and the South London and Maudsley Mental Health Trust. Between 2011 and 2013, Flaxman personally trained groups of mental health professionals at each of these trusts and they have in turn `cascaded' the training programme to their staff and service users. All four trusts have now added this intervention to their existing service provision, and have conducted a series of pilot projects to help evaluate the impact of this training on NHS staff well-being.

The enhancement of these staff support services in different areas of the UK is particularly significant in the current economic climate. All of these organisations have long waiting lists of staff requesting psychological support. In addition, budgetary constraints mean that the project partners have found it increasingly difficult to access the latest developments in therapeutic practice. As a result, all of the non-academic partners have shown appreciation for the opportunity to be part of the externally funded training activities.

More recently (October 2013), Dr Flaxman was invited to train psychologists and other mental health professionals working for the health psychology unit at Gloucestershire Hospitals NHS Trust. This training was attended by 11 practitioners, representing staff support, pain management, cancer support and weight management services. This point is made here to indicate the range of different services showing interest in the training, suggesting that impact is going beyond the earlier focus on staff support.

Impact has also been felt by non-NHS organisations. For example, the director of the City and Hackney branch of Mind (the mental health charity) arranged for all of the branch's available and interested mental health professionals to be trained in the ACT approach. This resulted in 15 people being trained by Dr Flaxman during 2013. The impact here was almost immediate: City and Hackney Mind has now been informed that it has secured funding from Trust for London to deliver ACT-based training to members of the local community considered to be at risk of dropping out of the workplace due to a mental health problem.

The programme leads of mental health nurse training at Middlesex University asked to become one of Flaxman's project partners. As a result, ACT-based training was delivered to two new cohorts of nurses in 2012, with the workshops embedded within the BSc in mental health nursing programme at Middlesex.

The training has also attracted international interest. Dr Flaxman was approached by the coordinator of the Butabika-East London Link (an organisation and network supporting knowledge exchange between East London NHS Trust Foundation Trust and the Butabika Hospital in Uganda). Subsequently, 20 members of a Ugandan network were invited to an ACT training workshop delivered by Flaxman at City. The UK coordinator for the project (Cerdic Hall) will continue with this training, utilising the book published by Flaxman and his colleagues. This is viewed as a welcome application of the ACT approach, as it will be used to support mental health workers operating with minimal resources in a challenging environment.

Finally, a stakeholder day was hosted by Flaxman at City in June 2013 (supported by the ESRC Follow-On Grant listed in section 3). This event was designed to communicate ACT-based training to mental health practitioners who were not directly involved in the above projects. The event was attended by 150 representatives from NHS Trusts and other mental health service providers from across the UK.

Impact on employees' mental health
The impact reported above focuses on how Flaxman's ACT-based training and research have helped to enhance mental health service provision within several organisations. It is also possible to demonstrate how the same programme of research has directly benefited a significant number of public sector employees. These beneficiaries include both those employees who were trained directly by Flaxman as part of the originating studies and the staff who have more recently been trained by the mental health professionals trained by Dr Flaxman as part of the projects described above.

Mental health data are available for more than 600 British employees who have attended Flaxman's ACT-based training. All participants who attended the training completed an internationally-recognised measure of mental health (known as the general health questionnaire, or GHQ). Analysis of change on this measure reveals that the training resulted in significant and durable improvements in people's mental health, with the beneficial effects being seen over a six month evaluation period. The largest benefits have been observed in those workers who joined the training with an above average (or `clinical') level of psychological distress (see Flaxman & Bond, 2010b).

Of these several hundred participants, 160 people were trained by Flaxman as part of an ESRC-funded project (Grant 1 listed in section 3). These staff were employed by two NHS Trusts (Northumbria and the Royal Free Hampstead) and a central government department. A further 150 NHS employees were trained in 2012 by a psychologist who had herself been trained by Flaxman as part of the project funded by Guy's & St Thomas' Charity (Grant 3 listed in section 3). The staff who attended the training in this project were all employed by the South London & Maudsley NHS Trust.

Most recently (between 2012 and 2013), more than 100 members of NHS staff (or trainee nursing staff) have been trained by staff support practitioners working for Northumbria Healthcare Trust, Central Manchester Foundation Trust, Camden & Islington NHS Foundation Trust and mental health nurse training providers at Middlesex University. All of these practitioners were themselves trained in the ACT approach by Flaxman. Evaluation of this `cascaded' training shows that it is having beneficial impacts on the employees involved. For example, as a group, the NHS staff who attended the training have reported significant improvements in their mental health (again based on GHQ scores) over a three month evaluation period.

The staff support team at Northumbria has been particularly active and successful in its use of the training. A team of four staff support psychologists has delivered the training to some 80 members of Trust staff. The results show that the training is delivering significant benefits particularly to members of staff with above average levels of distress and is continuing to have impact. In October 2013, Flaxman and the manager of the Northumbria staff support service presented these results at the Trust's workforce committee meeting. The meeting was attended by 20 senior NHS managers and chaired by the Trust's deputy chief executive. As a result of the committee's favourable response, the Northumbria staff support team is in the process of rolling out the training to even larger numbers of staff.

This training and research programme has had significant beneficial impacts, has reached a wide range of mental health service providers and has already improved the well-being of a large number of British workers. This work will continue to benefit from the close collaborations that have been created between Dr Flaxman's research team and the national and international project partners. In addition, a website "The Mindful and Effective Employee" has been created to promote the 2013 book by Flaxman and colleagues and to communicate the psychological skills training to a new generation of mental health professionals. The site includes freely-available resources for psychologists, occupational health practitioners, mental health professionals, coaches and trainers who might be interested in delivering the ACT-based training described in the book.

Sources to corroborate the impact

• `Confirmation of impact' emails from project partners cited in this report.
• Website for "The Mindful and Effective Employee": www.mindfulemployee.com.
• End of award report from the initial ESRC-funded project.
• Letters from four project partners supporting the successful follow-on grant application to the ESRC.