Daniel Knoepflmacher, MD (Host): Welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychology, research, and other important topics on the mind.

Population studies estimate that mental illnesses impact between 30-50% of Americans over their lifetime, leading to over $200 billion annually in healthcare costs and lost productivity. With the majority of adults spending significant portions of their weekdays working at their jobs, US employers have recognized the importance of supporting mental health in their workforce.

Over the past several decades, many companies have adopted employee assistance programs or EAPs and other resources dedicated to providing support for employees as a benefit That is free of charge. These types of employer-sponsored services have grown continuously over the years with more sessions being offered virtually after the widespread adoption of telemedicine platforms during the COVID-19 pandemic.

In today's episode of the podcast, we're going to explore this important piece of the continuum of mental health services provided in our country. We'll look at how these programs serve both employees and employers, how they've evolved over the years, and the benefits and challenges that come when mental health services are provided through work.

To discuss all of this with me today, I'm happy to welcome Dr. Randy Martin, who's the Clinical Director of COPE NYP, the employee assistance program at New York-Presbyterian Hospital, and an Assistant Professor of Psychology in the Weill Cornell Medicine Department of Psychiatry. Randy, thank you so much for joining me today now that we've all hunkered down after weathering a major winter storm yesterday. I appreciate you joining.

Randall Martin, PhD: Absolutely. Thank you so much for having me.

Daniel Knoepflmacher, MD: Well, let's start by asking you to share your own story. What led to you becoming a psychologist, and specifically how did you end up focusing on employee mental health programs?

Randall Martin, PhD: Well, as a child, my mother was in therapy, psychotherapy, as was my sister, and I would sometimes go along to those sessions to sit in the waiting room. And, honestly, I went to some psychiatrist's beautiful Victorian house and sat in this gorgeous waiting room, met her, and she sort of sat in this beautiful room and talked to people about their issues, and had control and autonomy of her time and her life. And it seemed like a great mission to help people with their mental health problems. And it seemed like a nice work lifestyle as well. And so, I got kind of intrigued by it. And then, ended up studying it in college and then, getting my master's and doctorate in counseling psychology and moving into the field.

And when I started, I was really interested in kids and families doing family therapy because it was the '80s and family therapy was just sort of on its nascent rise in popularity. And, I was fascinated by it. So, I became a child and adolescent and family psychologist. And I worked in that field for 18 years, moving from a line staff therapist to assistant, to a supervisor, to assistant director, that kind of thing. And I quite enjoyed it.

It's funny how one's life takes twists and turns that one doesn't expect. I was at the U.S. Open Tennis Tournament and I saw an old colleague that I used to work with. And she handed me a card and it said Corporate Counseling Associates. And I said, "Corporate counseling, what does this even mean?" And she said, "Well, it's an EAP." And I said, "What's an EAP?" And she explained to me what an employee assistance program was. And I was quite intrigued and I was fascinated with it. And I sort of followed up with some emails. And then, one day, six or eight months later, she emailed me and said, "Hey, our clinical director just quit, would you like to apply for the job?" So, I applied for the job and secured it and started what now has been a 24-year journey in the employee assistance program field.

Daniel Knoepflmacher, MD: Well, like you did at the U.S. Open, you said, "What's an EAP?" I wonder if some of our listeners may not be that familiar with that acronym and these programs. So, can you provide some history, some description of what these programs are, and if you have available some data on the prevalence and the scope of their work in employers across the U.S. today?

Randall Martin, PhD: Sure. One anecdote is when I started working in the field of EAP, I realized that I had worked for the past 18 years for organizations that had EAPs, but I had no idea that I had an EAP available to me. And that's a fairly common situation, so I'll explain that a little bit more later.

So regarding how the field started, it started in the 1940s and 1950s really as an effort that manufacturing and automobile industry folks noticed they had a problem with alcoholic men on the factory line getting injured, coming in late, doing shoddy work, et cetera, et cetera. And there was great concern about these men and their welfare and their impact on the bottom line, honestly. And so, peer support groups of men who had gotten sober started popping up. And they became the first kind of Iteration of what eventually became the EAP programs. But in the '40s and '50s and '60s, it was really an alcohol-based sobriety focused effort to help the workforce not abuse alcohol. And at that time, other drugs weren't as much of a factor, but alcohol and drugs. And so, that's kind of the origin of the field.

And then, in the 1970s, employers started to recognize that there are many other kinds of issues that are mental health or substance abuse-related that get in the way of an employee's productivity and cause the employee pain and distress. And they decided to broaden the scope of those programs and also to professionalize them. So, they started to hire master's and doctoral level counselors that come into the field. And for the first time, licensed mental health professionals began to take control of the field. And it moved from a peer assistance effort to professional mental health folks. And the model was that they would do some short-term counseling, it might be two or three or five or eight sessions, and then make referrals to longer term care or referrals to higher levels of care, should that be necessary for the person, like a detoxification program or eating disorders program, things like that.

Interestingly, in addition to the counseling piece, helping people with mental health issues and substance misuse issues, they also started a part of the field called Work-Life. And the Work-Life part of the field is really basically helping people with caregiving situations. Helping parents, for example, find summer camps for their kids or helping a middle-aged employee find a home health aide for their mom who's just gotten out of the hospital and needs a home health aide.

So, how is that relevant, you might ask? Well, the places like summer camps and home health aid agencies are only open during the day, and that's when employees are supposed to be working. And employers recognize that it takes a lot of time for a person to make dozens of phone calls to research summer camps in the middle of the workday, and that takes away from employees productivity and focus on their work. And so, they started these work-life programs, which are essentially sort of like librarians who then would contact, like, 10 or 15 summer camps and find out about availability and is it the kind of summer camp that I want for my child and what's the proximity and what's the cost and does the cost meet my budget and all of that. And so, they did all the research for the employee, and then would circle back to the employee and say, "I found these three that kind of meet all of your criteria. Here you go," saving the employee a lot of time.

In addition, full service, broad EAP programs started offering legal support as well, landlord-tenant disputes and child custody issues and divorce and all these things like that. They would allow you to speak to an attorney for free for 30 minutes or so and determine whether or not you wanted to utilize an attorney's services. And if you did and you chose that particular attorney, you could get a discount on their services.

In addition, they also became aware that financial issues are very distressing for folks and very distracting. And so, they started to offer financial counseling as well. So, you could speak to a financial consultant around saving for college for your child or developing a viable retirement plan and things like that and get some initial advice and education on financial literacy. So, they became very broad in the '70s and '80s.

Initially, employee assistance programs were internal, meaning the counselors were basically hired by the employer. And they only served that one employer client. What happened was an external vendor process began to emerge, or external vendors became professional EAP services that served hundreds or sometimes thousands of corporate clients and nonprofit organizations. And utilizing those vendors became more cost effective for employers. And so, there was a shift in the field from an internal EAP to external EAP because of the cost savings primarily. And that flourished for a good while.

But interestingly, as the field continued to emerge, some employers found that their vendor external EAP didn't really understand their industry, didn't understand what it was like to work in this particular space. And so, they were kind of generic and they became somewhat dissatisfied at times. And so, there started to be a movement back towards the internal EAP. And also, there's something that happened with external EAPs where they would install onsite EAP clinicians at various important clients of theirs. And that onsite clinician would only serve people from that company. They wouldn't serve the other hundreds of companies. And so, they then would get to know the culture of that company and the key stakeholders and whatnot.

I worked in external EAPs for-- I worked for four different external EAPs and now this is my fifth EAP. And this is an internal EAP because the New York-Presbyterian Hospital system and many hospital systems across the U.S. realized that working in healthcare is different than working in many other industries. And they began to really value having counselors and EAP professionals who understood what it's like to work in a hospital environment or in healthcare.

Daniel Knoepflmacher, MD: You mentioned that you even working before at places where there were EAPs and you didn't know they existed, do you have a sense of what percentage of employers, let's say over 500 employees, have these services these days?

Randall Martin, PhD: Yeah. There's a lot of market saturation in EAP, so almost all large employers, and I would sort of say 500 to a thousand employees have employee assistance programs. Every major corporation or large system has EAPs in place. It's almost universal. It's really the small employers, restaurants and local delis and things like that that don't have EAPs. Sometimes they belong to consortiums where they can band together as a group, like churches do that a lot. A bunch of churches will get together and purchase an external vendors EAP services.

Daniel Knoepflmacher, MD: So, its' something where now almost an expectation and as part of human resources, like they have this across the board, these larger employers.

Randall Martin, PhD: Yes.

Daniel Knoepflmacher, MD: Well, I'm curious, one thing that we've talked about this podcast before is how there's been some generational shift around the understanding and acceptance of mental health and mental illness and that there's maybe less stigmatizing kind of perspectives among a younger generation. So, there's been some shift. The pandemic was an important event in mental health in this country, I think for multiple reasons, because it became clear that it had an impact on people's mental health and it forced the use of telemedicine as a way to deliver mental health care.

I am wondering, you gave us a good background on how EAPs developed over the years, the decades. But what about the past five to ten years? Have you seen shifts that you've noticed working in this area?

Randall Martin, PhD: Yeah, it's a great question. Even before COVID, maybe 10 years ago, we started to see a shift in people and organizations recognizing that impaired mental health really impairs an employee's productivity. And it used to be that musculoskeletal problems were the main reason for short-term and long-term disability, but depression overtook musculoskeletal problems and now is the worldwide number one reason for short-term and long-term disability. And employers began to recognize that.

And one thing I didn't say about EAPs is that you have two clients as an EAP professional, the small C client, which is your individual client that you're doing counseling with or helping, and the large C client, which is the organization. And the organization pays for the employee assistance program, pays the salaries of the workers, pays for everything. And they're doing it for both their own reasons and for the employee's welfare. Obviously, many employers do have concerns and want to have employees who are happy and healthy and mentally fit. And they care about their employees and it's one reason why they have EAPs.

But another reason is that people with mental health and substance abuse problems are problematic workers, right? They call in sick too much. They're tardy. They make errors; in the healthcare industry, medical errors. And they get into conflicts with their coworkers, and it creates all kinds of issues. And so, to have a productive workforce, you have to have a mentally healthy and physically healthy workforce. And so, employers started to put more stock in mental health resources. And that this was even before COVID. And then, COVID happened.

And people kind of started to talk about their own mental health struggles much more openly on social media and even in the media itself. People like Carson Daily on the Today Show talk about panic attacks; Naomi Osaka in tennis took a bow away from tennis because she was overwhelmed; Simone Biles, the famous gymnast, she stepped away for a time from all the pressure and the perfectionism of gymnastics; and Michael Phelps, the Olympic swimmer, famous for supporting mental health issues.

So as media figures started to come out and talk more openly, and everyone during COVID started to acknowledge with less concern about stigma that they were struggling, that really causes zeitgeist. it just sort of changed the way things were. And then, you have generational things in that younger people are more open to talk mental health issues, and many of them have been in therapy and many of them have been on psychotropic meds, even going into college and things like that. They're more open.

I was on a college tour with my son. And we were walking around with the sophomore young student who was leading the group. And we walked by the counseling center and she said, "Oh, and here's the counseling center. I go to counseling here, and you should consider that too, because college is really stressful. And this is a great resource for you guys." Now, like 20 years ago, that likely would not have happened. But she was proud to say she was in therapy and she had no issue with it.

Similarly, we have a table, that promotional table for our EAP that greets medical residents on their first days in the hospital. And these are typically 20, 26 to 32-year-olds. And they came right up to our table without being concerned about other people hearing. And they say, "Hey, like to get hooked up with a new psychiatrist. I just came from Indiana and I need a new prescriber. Can you help me find a psychiatrist?" or "I'd like to get into therapy at the start of this process," or that kind of thing. And they would talk about it no shame and no compulsion to sort of hide things, that kind of thing. So, there's a lot of things going on these days that have opened up the field of mental health and it's just amazing. It's great news for the field.

And then, I think the telehealth thing, like mentioned, also is important. Therapists themselves were quite skeptical about the effectiveness and viability of telehealth as a way of delivering services prior to COVID. Then, COVID happened, and everyone was forced to start meeting with people via video and telephone as opposed to in-person. And what therapists found and what research has demonstrated is that virtual therapy is quite effective. I do still think that it's preferable to see people in-person when possible. And there's certain nuance that's lost. But you can get a lot of wonderful help from telehealth.

And that broadened the field also because therapists started opening up their hours earlier and later because they didn't have to travel to an office to do the therapy. And so, that made it even more accessible for people because people were being offered more early morning and late evening hours. So all in all, there's really good news in terms of people getting help from their EAP and from therapists in general, since stigma has started to fall away.

Daniel Knoepflmacher, MD: And you offer through the COPE NYP program here, both telehealth but also in-person offerings for employees.

Randall Martin, PhD: We can see people in-person. But in terms of office location and whatnot, it's challenging because we're not located in any one of the major hospitals. And so, office space is an issue. So, I'd say 98% of our sessions are virtual at this point.

Daniel Knoepflmacher, MD: And I'm curious, given everything you described there, have you heard in the EAP world and maybe even within our own system about an increase in usage over, let's say, the past 10 years, that there's more people seeking the services as a percentage within organizations?

Randall Martin, PhD: Yeah. EAPs, generally, you sort of broadly look at EAPs across the United States have a utilization rate typically between 3% and 5% of the population, which seems like a small percentage. But when you're talking about tens of thousands of employees, it still adds up.

That said, we'd still like to see more utilization. There has been some slight uptick over the years, but it hasn't been dramatic. And there's also been the advent of mental health apps that have been become popular and meditation and mindfulness apps. So, some people are also attempting to ameliorate their mental health issues using sort of non-therapy kind of tools like these online cognitive behavioral therapy apps and other tools like that.

Daniel Knoepflmacher, MD: You spoke earlier about the culture of the companies or institutions that are being served by EAPs and how sometimes the external EAPs, you know, had to either learn about their culture or these places would adopt an internal EAP. And here, we have at New York-Presbyterian internal EAP, which you direct. And I'm wondering, here at a large New York City hospital, thousands of employees over multiple locations, what are some of the unique mental health risks that you see maybe compared to other industries that you've worked in or know from your experience in EAPs?

Randall Martin, PhD: Yeah. Hospital systems and healthcare systems differ from many industries in that hospitals never close, right? We're open 24/7, 365, by necessity. And there's people on every shift. You know, you have the day shift, the shoulder shift, the evening shift, the overnight, and the weekends and holidays. There's always someone working in hospital systems. And so, I think, there's the unique issues of shift workers or people who work overnights and their sleep hygiene and work-life balance issues that get in the way of them feeling really at their best. So, shift work is one thing.

The other thing is that hospital workers are exposed to vast amounts of human suffering, right? They're seeing patients and families when they're at some of the most challenging and difficult and painful moments of their lives. And the amount of pain that they're exposed to, watching people deteriorate, watching people die, just seeing people come in with horrific injuries, it's filled with trauma. And there is some secondary trauma that happens to a lot of healthcare workers, especially providers, EMT workers, nurses, physicians, residents, and really everyone, patient transport, they're all exposed to seeing these things. And that's very draining and very hard for people. It makes it different than many other industries.

And then, the last thing I'll say about the environment is that, very unfortunately, the healthcare industry is the number one industry for workplace violence. And so, there's a lot of patient-on-staff violence. But there's also family members and visitor violence upon staff. Just think about it, when people come to a hospital, they're not in a good place. They're frustrated, they're worried, they're angry. They may be angry at the healthcare system or the provider for not being able to give them the outcome that they had hoped for.

And so, what happens is that, especially in the past few years, similar to what's been going on in the airline industry with the way people treat flight attendants, people have gotten unhinged. There has been horrible physical violence. But there's also been sort of psychological trauma related to horrible racism, homophobia, sexism, et cetera, by patients and family members. And it's deeply unfortunate, and I'm hoping that we'll be able to turn the corner on this workplace violence issue. But it's very, very hard the stress level that both patients and families are at coming into the system.

Daniel Knoepflmacher, MD: That is a disturbing trend. And it's something where, you know, not only do you want to think about how to support employees through that and then, also in the system, what are ways that we can help mitigate that violence on the other side in terms of the family and the patients that are reaching that point, which is maybe a discussion for another podcast.

But I want to dig into a lot of what you just said there. One thing that you alluded to was the percentage of people using it, in the 3-5% range. There's lots of high quality services available, and yet I am sensing that many employees hesitate to use them. So, what are the barriers here that you see most often? A lot come to mind thinking about confidentiality concerns, the time it takes when you're a busy healthcare professional, perhaps even worries about professional repercussions. Can you speak to this?

Randall Martin, PhD: Yeah. Well, stigma remains. Despite the progress that we've made there, there still is a stigma. So, that's one and barrier about seeking mental health support. Especially in certain cultures, there's more stigma than others. And then, it's really hard, I think, for people to trust the confidentiality when you're talking to a counselor who also works for your employer or is associated with your employer. And so, there's some skepticism that happens for people, saying, "Is it really confidential what I say? If I talk about my boss in this really negative way in this counseling session, is that going to somehow come back to that manager or supervisor? Will they find out that I've said these things?"

And then, there's other concerns about, "Can they interrupt my ability to work if I mention having a mental health or substance abuse issue that does actually impair my functioning?" And there are limits to confidentiality, honestly. If you're a danger to yourself or others, we may have to take steps to make sure that you or other people are safe. So, we're not going to allow a surgeon who is currently actively using substances during their workday to proceed. We would have to step in and say, "We're going to need to intervene." If you're not willing to remove yourself from this situation and not do surgery, then we will have to step in and prevent that from happening.

So, there are certain circumstances where confidentiality is broken, and people are concerned about their professional licensure. Providers, physicians and residents and nurses and other licensed providers are concerned that, if they're not fit for duty, that that will come back to haunt them. Now, some people get around that by finding private mental health services, not even through their insurance, because they don't want a paper trail. They can hire a private therapist that's not in the EAP or not through their insurance and pay cash. But of course, that's only something that the more affluent employee can afford. And other employees who don't have as much money don't have that luxury. And so, some of them might shy away from seeking out psychotherapy services.

Daniel Knoepflmacher, MD: I am curious, what are the most common reasons that people seek the care from an EAP?

Randall Martin, PhD: Yeah, I'll tell you that, for all the years that I've been in EAP, almost always, the number one and number two problems are anxiety and work stress, and personal stress. So, I'll consider stress sort of a subclinical level of anxiety. So, it's just like the normal hassles of day-to-day work, the trouble with work-life balance and all of that. So, people come in and they talk about the stress of being a working parent, caring for their elderly, and aging parent while they're trying to work full time and things like that. So, personal stress, work stress, very common. Of course, people come to the EAP to talk about feeling overworked, underappreciated, micromanaged, all of that, relatively typical work stress. And then, there's sort of higher level of anxiety. So when it gets to generalized anxiety disorder, and it becomes even more impairing, we see lot of anxiety, way more than depression. And a lot of people in the public don't realize that anxiety is much more prevalent than depression out there. But we do see good amount of depression. That's another one.

But another thing that people don't maybe recognize is that one of the main issues EAPs hear about are couples issues. Because when you have basically a middle-aged workforce and many of whom are either married or in a couple or living with someone or in a relationship, that those relationship issues can really derail someone and cause what we call presenteeism. Presenteeism is when someone's at work and they're so distracted by their personal problems or their relationship problems that they can't fully be there and can't be sort of firing on all cylinders. So, we hear a lot of people talk about couples issues. We hear parents talking about concerns about kids.

One interesting thing that we've seen, heard a lot of lately, it seems to me-- this is kind of anecdotal-- but a lot of workers who are parents worried about their adult sons. The young adult males are really not doing well in American society right now. And there's a lot of books about that right now. One by Richard Reeves, Of Boys and Men. He's a researcher and a writer, great book, about the problem that males are having launching from their families and developing successful careers and getting out of the basement and starting to have relationships. And there's a lot of problems with this sort of 20 something males in particular that we've heard about, some suffering from fairly significant substance abuse, a lot of serious overuse of marijuana, where they're just sort of paralyzed in their basements and really not thriving. We've heard a lot about that.

And then another thing that I think is really important, a really central thing that EAPs hear about a lot is caregiving. Twenty to thirty percent or more of adults are in some kind of a caregiving role, whether they're caring for kids or caring for disabled siblings or caring for their aging adult parents or other relatives. There's a huge impact of caregiving on people, because caregivers spend a lot of hours doing all those extra activities and on top of their normal life activities that they have to do, especially when it's more significant. You have a disabled child or really aging parent. It takes a huge amount of emotional energy. Finances, are impacted. Caregiving has such an incredible impact on people and their ability. It drains people and their ability to function well at work. It just sort of takes away. I think there really should be a lot of focus on caregiving in the upcoming years.

Daniel Knoepflmacher, MD: This population, of course, they're professional caregivers. So, I imagine they're at higher risk in some ways because they have expertise that families can really lean on and call them to do that work outside of their work. So, I imagine that comes up a lot.

Randall Martin, PhD: That's a very good point. We do hear that anecdotally from people who are physicians and other providers, nurses they turn to as the person in the family who knows more about medical issues than anyone else. And so, they become kind of the family doctor as well as their day job.

Daniel Knoepflmacher, MD: This brings up something else that is important in the kind of work that we do that's high stress, high stakes. And that's the concept of moral injury. The psychological harm that can come from an individual feeling like their own moral beliefs or values are being violated in the work that they do. So, I'm curious, if you could talk about how that might emerge in healthcare environments and how you've been able to support employees who experience this.

Randall Martin, PhD: Yeah, it's very distressing for a person whose life is devoted to caregiving, like you said. These providers, their mission in life is to give care to other people, and that gives them meaning and value and purpose. And for someone to feel like they can't give the proper kind of care because they're overwhelmed by the number of patients that they're asked to attend to at the same time. So, they don't feel like they're giving proper attention or focus to each individual patient. Things like that can cause moral injury. It's really a tough thing to deal with, because there's not any easy solutions to these kinds of things because how can any one individual employee impact the staffing ratios of a hospital system that has tens of thousands of employees, you know? There's only so much you can do. You have to help people not be perfectionistic and allow themselves to be good enough at what they do and to accept that the system's never going to allow them to provide the perfect level of care, that kind of thing. So, there's sort of like self-compassion there.

And then, we tell people to escalate issues to their supervisors, managers, senior management. They have ethics lines, they have HR lines that they can call and say, "This situation is perhaps going to cause or potentially could cause injury or not the best kind of treatment for this particular patient or family."

So, there are some avenues that they can go to. But I think self-compassion is probably one of the the main issues. And there's also like, if you look sort of very bird's eye view at it, political activism, right? They can get involved in causes that may serve to help them feel that at least they're bringing it to the attention of the government or authorities or relevant leadership so that they can say, "I tried my best to tell folks about these situations and to draw attention to it."

Daniel Knoepflmacher, MD: That's where advocacy can play a role. I want to ask you about prevention. We've talked a lot about dealing with the problems that come up and how you help support people during that, but what are examples of effective programs for maintaining employee wellness, hopefully preventing some of these things we just talked about.

Randall Martin, PhD: Yeah, I really like this topic. Prevention and early intervention are great aspects of an employee assistance program. And I didn't really go into the fact that employee assistance programs, in addition to offering individual counseling and couples counseling, things like that to folks, they also do organizational interventions.

And one of those interventions that they do are psychoeducation through webinars or seminars. And so, we do about two a month here at cope to the general population of the hospital on all kinds of relevant topics. We have one coming up on the difficulties of shift work and how to best manage those stresses and strains. We've had sleep hygiene and relationship issues and dealing with kids. And there there's just so many different topics that we bring up.

So, I think that, as therapists, one of the things that we first think of in terms of helping people is to do psychotherapy with them. And that's great. But not everyone has the time or the money or the inclination to do that. So if we can provide them with psychoeducation through these webinars that we often recommend books and websites and things like that, that they can turn to, some people like to learn on their own. And also, when they're listening to a webinar on these topics, they might self-identify and on the early stages of their distress, "Oh yeah, I really should get to the EAP." And of course, at the end of every webinar, we talk about the EAP and its availability and that kind of thing. So, I think that's one thing that we do.

Another thing that we do organizationally are critical incident response debriefing groups. And so, after, for example, a workplace violence incident or a death of a coworker or a death of a beloved patient, things like that, we'll send a counselor out to a work group to meet with them and to talk about their grief or their distress, their trauma. And we will catch them early on right after this happened and help them through that process, which can potentially prevent people from developing longer term issues.

Another thing I'm quite proud of is EAP is kind of a passive benefit. We give people a website and a phone number and an online intake that they can reach out to when they want to, and that's great. But we are kind of sitting here waiting for them to contact us. And one of the things that some of the high quality EAPs internal and external are doing right now are sort of proactive outreach programs. So, we have four currently running proactive outreach programs at COPE NYP. One is two security officers who've been involved in some kind of incident. As I mentioned, workplace violence is a huge issue, and the security officers are some of the first people on the scene, and they are dealing with really unpleasant and difficult situations and often get involved in trying to remove people from the hospital who are disruptive or aggressive and things like that. And some of them get hurt psychophysically and some get hurt psychologically. We reach out to every security officer in a proactive way and say, "Hey, we heard this happened. We're here for you. Do you want to us to arrange counseling for you?"

We also do that for people going on parental leave. So when I think about transitions that people go through, like becoming a new parent, a very, very stressful, huge impact on a family. And so, as people go on parental leave, we're contacting them proactively and saying, "Hey, did you know that the EAPs out here and can help you or your household member?" That's the other thing about EAPs is they can also help household members. And so, that can be really important, because you might be a father that's taken parental leave when there's a new baby that's arrived in the family. But you might be concerned about your wife who might be developing postpartum depression, for example. Well, we tell you, "Hey, you know, your wife's eligible for the EAP. Let's get her help." And so, we'll pull the wife in for help.

We also are doing proactive outreach to people who apply for hardship grants. We have a hardship program at NYP to help people who are in dire financial circumstances due to emergencies and things like that. And we ask them on the form like, "Would you like the EAP to reach out to you?" And if they check the box, we'll reach out to them. And we also do it for new hires because the first day you get your benefits package and you learn about all the massive benefits that your organization offers, and you immediately forget that the EAP exists. So, what we do is three months later, we call you and say, "Hey, we're out here. We're here. Having a new job is stressful. How can we support you?"

Daniel Knoepflmacher, MD: So, you mentioned earlier that you're really serving two clients. Obviously, all the employees that we've been talking about who come to use the services of the EAP, but also the employer, the organization in this case, in your job, NYP, New York-Presbyterian. And I'm curious, how do you think from a systems perspective in serving the employer how to balance the demands of a high productivity, high stress workplace with the creation of a sense of psychological safety for the employees and just general employee wellbeing?

Randall Martin, PhD: Yeah, good question. You mentioned psychological safety. I think creating an environment from a leadership perspective of psychological safety is vital. And what we mean by that is basically a culture of compassionate leadership and a culture of forgiveness. And you don't often hear people talk about forgiveness as a concept in business, but having compassionate leadership is not being punitive when someone is struggling or is having trouble with the high stress demands of a job. But really mentoring them and showing your own vulnerability as a colleague, and also helping them learn the very best ways to manage these extremely high stress jobs based on your experience and their other peers experience, and being forgiving when people are not perfect, being forgiving when they make mistakes.

Dr. Everett Worthington, world's foremost expert on forgiveness, who I've recently met-- and I'm really excited, I'm going to have him come speak to one of the conferences that I'm organizing-- talks about that, that it's vital for us to have a leadership and management structure that is human and is forgiving. And leaders should know a little bit about the personal lives of their workers and understand that their workers' stresses and strains that are outside of the workforce. Like we talked about caregiving, if someone has their parent hospitalized and is needing extra flexibility in terms of time off or things like that, then giving that person that grace and not being rigid as a leader, as a manager. So, I think, there's a lot that EAPs can do in terms of helping management and leadership foster that culture of compassionate leadership.

Daniel Knoepflmacher, MD: That's such an important thing to highlight. I mean, as someone who is a leader with maybe a small L, in my program and then looked to the leaders in our organization during the pandemic who would come out and speak regularly and show vulnerability, show support. It really is at the center of psychological safety that you need that in the hierarchy in order for employees to thrive.

Randall Martin, PhD: Absolutely.

Daniel Knoepflmacher, MD: I want to though turn to something that's inevitable in life and even in this work I'm sure, which is conflict. Now, when you have two clients that you're serving, inherently, there's going to be times where there can be conflicts. I actually worked on a book on taking care of the mental health of healthcare workers and wrote a chapter on this specific topic about the conflicts that come from the needs and demands of the individual that sometimes can be, if not directly, in conflict of what the needs are of the organization, at least in attention, let's say.

So as somebody who's serving both of these clients as well as you can, how do you navigate these conflicts that come up? Maybe in the most general sense, some examples of ways that you've been able to do that.

Randall Martin, PhD: Yeah, EAPs don't typically do like mediation between two coworkers who are in conflict. There are some that do, but it's fairly rare. We don't do that in particular. But we will work with an employee around how to best manage conflict because sometimes people either shy away from it entirely And then sort of suffer in silence, which is very unfortunate for them, or they go about trying to resolve it in an in elegant way. And then, that doesn't serve them either. So, a lot of it is sort of helping people approach conflict management in a professional yet assertive way.

Now often, the conflict is between a worker and their manager or supervisor. And that can be really, really tricky. So, you want to have them attempt to resolve that conflict directly with the manager supervisor to the degree that they can, and have that initial discussion, and hope that that moves the needle. But if that doesn't work, there are possibly other options for them. They can go to other leaders or to HR or the RESPECT office at NYP and talk about the issues that they have with that leader. It can be tricky though. It's a tricky area, honestly.

Daniel Knoepflmacher, MD: And even to stay on this topic, sometimes there are conflicts, not necessarily between two individuals, but you gave an example, which I think maybe would be too clear if there was an impaired, let's say, surgeon. But there are times when maybe, let's say, an employee is struggling and their struggle impacts a service or productivity or something in the organization. There's pressures from the organization that they need to take care of that need, that person's needs. Whatever support and care they need, you have to protect their confidentiality. I'm just trying to throw a few things into the mix. I guess, how do you advise the people working with you in EAP how to skillfully navigate those kinds of things where almost the conflict is in you being in the middle of that rather than directly between two individuals who are having a conflict?

Randall Martin, PhD: Yeah. When an individual is showing performance issues or work-related problems like irritability or that kind of thing with coworkers, or even worse, that may belie an underlying mental health or substance misuse issue, there is a process in EAP that's called the management referral process. And at NYP, they call it the administrative referral process. It's called different things at different organizations. But usually, management referral or administrative referral. If a person's issues are sort of leaking out into the workplace and causing problems, if they are made a management referral or administrative referral, they can be asked to go to an in-person assessment to assess their fitness for duty. And if they are deemed by the mental health professional to not be fit for duty because of those problems, they can be temporarily put off work on administrative leave or short-term disability and referred for help, either through the EAP or through a provider through their insurance or other resource. And that person often will be sort of taken off work for a few weeks and then asked to get that kind of more acute help. And then, come back to for a reevaluation before they're allowed to reenter the workforce. And the most significant performance problem areas, that is the process.

Daniel Knoepflmacher, MD: So, it sounds like there's something in place there, though. I imagine for the EAP provider, they're at the center of that, and that's something that they have to shoulder. But there's a process to support them because see all of that as part of that psychological safety too so that things don't necessarily become punitive.

Randall Martin, PhD: Yeah. The sentiment behind the management referral or administrative referral is that we want to get the employee back on the road to health and recovery and productivity and to be a great worker again. It's not meant to be punitive, but it is meant to sort of protect the other coworkers who may have been impacted by this person's issues and to take a sort of a time out of that and get the person help.

Daniel Knoepflmacher, MD: I want to turn to outcomes. I am sure that you collect data and these programs, I know, are making a positive difference for individuals in this organization, other organizations. So, what do you guys do to measure outcomes?

Randall Martin, PhD: Yeah, it's a great question and it's important. And it's important for us to demonstrate those outcomes to the big C client, the organization. So, we do some psychological measures. We do the PHQ for depression and the GAD for anxiety. And we do the Workplace Outcomes Suite, which is a common EAP metric. So, these are pre and post measures. So before someone starts in the EAP, we give them the PHQ, the GAD and the WOS. And then, when they're done with their EAP sessions, we do it again. And then, we can demonstrate decreases in anxiety, decreases in depression. And the WOS measures a variety of things, including life satisfaction, work engagement, absenteeism, presenteeism that we discussed before, and things like that. And so, we can really demonstrate some very positive clinical outcomes based on these standardized measures that are common in the field. So, we have that.

And then, after a person uses our service, we give them a Net Promoter Score Questionnaire or NPS question. Not everyone knows what an NPS is, but you've definitely been asked it before. It's the question on a scale from zero to ten, how likely are you to refer a coworker or colleague to this program? So, you've heard that in various other-- you know, how likely are you to buy this product, or to refer, you know, a friend to buy this product, things like that. So, it's a very commonly asked business metric, and it's very useful. We have very positive NPS scores. And we also ask a counselor satisfaction score and a program satisfaction score. So, we have that as well, showing very high levels of satisfaction with their experience with us.

Daniel Knoepflmacher, MD: Any other notable trends or things that have emerged from all of this data that you've collected?

Randall Martin, PhD: I think our biggest users are in the hospital system are nurses. Nurses are a very highly stressed group of individuals. They're also one of the biggest roles in the hospital of course, so that's another reason why they're the number one. But nursing is a very stressful job, and it's become apparent that many nurses are struggling with their roles. And that's certainly something I notice.

Physicians are relatively reluctant to ask for EAP services. And for those reasons we've discussed before, just concerns about licensure and things like that, I believe is the main reason, although the younger clinicians and the residents have really little hesitancy. So, we're seeing that among young residents, they're quite robust in their use of the program. And that's great.

Another thing that we have a sub-program called COPE GME, which used to be called the House Staff Mental Health Program for residents. And we have kind of a specialized element to that program in that, in addition to the short-term counseling, we also can provide psychotropic evaluation, psychotropic medication evaluation, and some med management. And there are a good number of residents who take advantage of that service. And so, I think that is sort of an area that EAPs should really look at going forward, is sort of involving psychiatry and prescribers in the process of providing EAP support. And it is something that some EAPs are beginning to look at and some other players in the field of EAP and related are looking at is, like, increasing access to psychotropic medication.

Daniel Knoepflmacher, MD: I want to ask you to take out your crystal ball and think about the future and what do you think are maybe some trends-- promising or concerning-- that we will see in workplace mental health, let's say, over the next decade?

Randall Martin, PhD: Sure. There are some peer support programs that are really interesting and popular. Some take the form of like a bulletin board where peers can connect with other peers even across systems. For example, we're talking about nurses, like, you could log on to a peer support program that connects nurses across many different healthcare systems and feel a lot of parallel support and peer support from other nurses. So, I think peer support and peer support apps will continue to rise. Mental health apps are ever growing. There's hundreds of them now.

I would say we'd have to be careful about which ones we choose to use, and that's not always easy. Of course, there's a rise of sort of AI chatbots and tools related to therapy. I think, there's a lot of concern among therapists about people using chatbots as their primary source of mental health support and how that can go down a wrong path. I think there's great promise in the field around using chatbots, especially as an addendum to therapy, but I would rather not see them take the place of actual human therapists for obvious reasons. And it can go quite awry.

I think, the sort of use of wellbeing coaches, we have a coaching program at NYP as well, who help people make positive lifestyle changes. They're not psychotherapists per se, but they're skilled coaches who can help people with diet and nutrition and exercise and sleep hygiene and stress management in all manner of things. And the use of coaches as an additional support for employees is great.

I think there's mentorship programs that are really great helping especially people who Maybe our line staff, but get promoted into leadership. And then, how do you become a leader? Because they teach you how to be a physician, for example, but they don't teach you how to lead other physicians. And there's a great need for mentorship and to use the wisdom of employees who've made that journey already to improve the way you lead. And I also think that we will see a continuation of the move from fully external EAPs into hybrid and internal EAPs for certain industries that, like healthcare, where it is really quite a unique environment.

Daniel Knoepflmacher, MD: Thank you for looking into the future in this way. I want to ask one last question to you, and that's again thinking more in terms of the big C client, these institutional organizations that use EAPs. If you could recommend one thing to employers to consider when thinking about employee mental health, what would it be?

Randall Martin, PhD: Well, to improve employee assistance programs and make them more effective, having a richer model is great because the modal number of EAP sessions in the country is five, I think. But many are three-session models or two-session models, and that's just enough to sort of do a basic assessment and then make a referral to insurance.

And I don't think that that's a great program, because some employees especially, those in sort of the middle and lower income ranges are never going to make that transition to longer term therapy because they have a copay that is difficult for them to manage. And so if you have a rich EAP model, like we have an eight-session model, for example, or up to eight, they can get short-term counseling and sometimes that's enough. Sometimes that will get them through their period of distress or point them in the direction of where they need to go or maybe even leading them into books or other community support that doesn't cost them extra money.

So, I think, enriching your EAP and also promoting it aggressively and assertively promoting it and sort of making sure that the population really knows that it's out there, and making it really visible. And I think it cascades from the leaders. You know, if you can touch the leaders and supervisors and managers and senior management and help them cascade that information down, and also to the extent that they're comfortable, if a leader can say, "I've been in therapy. I've been on meds. I seek this kind of help for myself, and here I am, at a high level in this organization," that can really make a vast difference in the culture of an organization, and showing your vulnerability and showing your willingness to say, "Hey, all of us need little extra help once in a while."

Daniel Knoepflmacher, MD: It goes back to that psychological safety that you spoke about. And I guess it's about really convincing the employers, the organizations, that there's a real return on investment in enriching these offerings.

Randall Martin, PhD: Absolutely. And there clearly is.

Daniel Knoepflmacher, MD: Well, that's a good note to end on. Randy, thank you so much for joining me on this episode of the podcast. It's great to get your expertise from so many years. I guess you said 24 years of experience, working in and leading programs that are dedicated to improving workplace mental health. A pleasure to just have you here and learn all about this from you today.

Randall Martin, PhD: Thank you so much, Danielle. I really appreciate being here.

Daniel Knoepflmacher, MD: And thank you to all who listen to this episode of On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on all major audio streaming platforms that includes all of the big ones like Spotify, Apple Podcasts, YouTube, you name it.

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