Application of an Evidence-Based Intervention for Improving Employees’ Mental Health
Submitting InstitutionCity University, London
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
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.
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
- 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
References to the research
Flaxman P.E. & Bond F.W. (2010). A randomised worksite comparison of
acceptance commitment therapy and stress inoculation training. Behaviour
Research and Therapy, 48, 816-820 10.1016/j.brat.2010.05.004
(Behaviour Research and Therapy is a peer-reviewed journal and is
ranked 15th out of 354 by SJR in the area of Psychiatry and
Flaxman P.E. & Bond F.W. (2010). Worksite stress management training:
Moderated effects and clinical significance. Journal of Occupational
Health Psychology,15, 347-358 10.1037/a0020522
(Journal of Occupational Health Psychology is currently ranked 8th
out of 126 journals in the field of applied psychology).
(New Harbinger is the leading American publisher for books on acceptance
and commitment therapy.)
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: 5th January 2009. End date: 30th June 2010.
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 1st November 2012. End date July 2013 (9 months).
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
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
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
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
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
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
- 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.