Ahmed could tell his team was on edge. Recent layoffs in the industry and poor company performance had his people worried about job security. But he was most concerned about Melia, one of his direct reports. She had been taking more sick days than usual, and when she was in the office, she seemed distracted. In meetings, she lacked focus. Once a high-performing, enthusiastic colleague, she now seemed low-energy, and her productivity was suffering. Offhand remarks from other team members suggested she was struggling with eldercare for her ailing mother. One day, Ahmed found Melia weeping in an empty conference room. He apologized awkwardly and retreated to his desk, unsure of how to proceed.
Managers like Ahmed (a composite of clients we have worked with) often receive first aid training to address physical injuries in the workplace, but very few are armed with the skills to respond effectively to mental health crises that might arise within their teams. The need for such training is acute. Managers today are leading anxious workforces, with many employees grappling with stressors such as social isolation, inflation, an uncertain economic outlook, the lingering effects of the Covid-19 pandemic, and rapid technological advances.
In addition to lacking training with regard to emotional well-being, many managers have been taught that employees’ personal problems are none of their business. However, younger Millennials and Gen Zs have grown up in a culture that increasingly recognizes the importance of mental health and generally views therapy as a normal and accepted part of life. Not only are younger employees more open to discussing mental health, they also are experiencing anxiety disorders at higher rates since the Covid pandemic, further indicating a need for managers to be equipped with mental-health first-aid training.
Fortunately, the principles of frontline intervention are not as complex as one might think and can be readily learned by nonclinicians. Specifically, cognitive behavioral therapy (CBT), a talking treatment that focuses on the connection between thoughts, emotions, physical sensations, and behaviors, is increasingly being taught to managers as part of mental-health first-aid courses. This is especially the case in the United Kingdom, where one of us is a counseling psychologist (Bhatti) and the other is a professor of leadership (Roulet).
No one expects bosses to conduct therapy sessions with subordinates; as the phrase “first aid” suggests, the goal is to provide rudimentary, on-the-spot care until the individual can get professional help, if it’s necessary. This kind of support is particularly valuable right now, considering the difficulty many face in accessing adequate, timely, and affordable mental-health care. With the right training and tools, good managers can help reduce the gaps in treatment.
In this article, we outline how managers can use principles from CBT in a three-step process to help employees improve their emotional well-being and to build a more supportive organization.
What Is Cognitive Behavioral Therapy?
Over the past half century, cognitive behavioral therapy has emerged as the preferred evidence-based treatment for many mild psychological issues. For example, a 2016 meta-analysis of 144 studies found CBT to be an effective treatment for depression and anxiety disorders. And a 2019 systematic review of 34 randomized controlled trials confirmed its effectiveness in combating depression and recommended it for use in primary care. (Researchers agree that CBT is not an appropriate treatment for severe psychoses such as schizophrenia.) In the UK, cognitive behavioral therapy is considered the gold standard and is recommended by the country’s globally respected National Institute for Health and Care Excellence guidelines as the first line of treatment for low mood and anxiety, which are the most common mental-health difficulties reported by people of working age. In the United States, many medical bodies, insurance companies, and government health providers recommend CBT as a first-line treatment for disorders such as insomnia, PTSD, and anxiety.
The efficacy of CBT in the workplace has also been well-documented. For instance, a 2020 review by Deloitte of numerous academic studies found CBT sessions with a therapist to be a cost-effective way to help employees manage issues such as absenteeism, stress, and anxiety. What’s less understood is whether CBT retains its effectiveness when administered by managers, but evidence suggests that it might.
CBT is already being used safely by nonspecialists in many low- and middle-income countries experiencing severe shortages of trained clinicians. A 2020 academic review found that delivery of CBT-based interventions by nonspecialists in such environments was “acceptable, appropriate, and feasible” for a range of common mental disorders, though the study found that more research was needed to better evaluate their outcomes.
One of the core tenets of CBT is that it can be self-administered once its principles are understood. This is backed by evidence from mental health nonprofits, such as MIND, that promote self-directed CBT learning and practice. A recent study found that CBT self-help materials were effective in supporting primary care nurses in treating patients’ low-level depression.
The use of CBT-based mental-health apps by employees of major corporations further attests to the treatment’s potential effectiveness outside the therapist’s office. Companies such as KPMG, Uber, Bank of America, Microsoft, and Salesforce all offer online CBT-based tools to their employees. Some organizations and even national health systems, such as the UK’s NHS, are experimenting with AI chatbots to deliver CBT, demonstrating growing confidence in its deliverability without a trained clinician’s direct involvement.
Many companies in the UK and elsewhere are already offering mental-health first-aid training to managers and employees. In the United States, more than 3,100 companies have offered the training, which more than 3 million people have completed, according to the National Council for Mental Wellbeing. Companies that have offered the coursework include Bank of America, Gillette, Starbucks, and Unilever.
Despite this evidence base, however, many managers remain unfamiliar with CBT’s principles and how simple workplace support can draw upon them. Recognizing this, let’s now explore those principles and their practical applications in more depth.
How to Administer Cognitive Behavioral Therapy
CBT is far more straightforward than traditional psychoanalysis methods used by trained professionals who probe childhood memories. CBT emphasizes the specific condition being treated without delving into any underlying trauma or psychoses. It is typically conducted within a predetermined time frame, unlike other open-ended therapeutic approaches. CBT’s proscribed scope and time frame not only contribute to its effectiveness but also make it more attractive to insurance companies, which favor modalities that do not necessitate long, potentially indefinite, courses of treatment.
CBT focuses on the interconnections between someone’s cognitive state (thoughts and thought processes), mood state (emotions and feelings), physiological state (physical sensations in the body), and behavioral state (actions and behaviors). Using CBT, individuals take control of what they think and do, which can positively affect their emotional state and thus change their behavior, leading to a virtuous cycle.
As an example, consider a person with social anxiety who consistently avoids social situations for fear of being judged or criticized. CBT helps the person examine the way the states interconnect:
The person has negative thought patterns such as “Everyone will laugh at me” or “I’ll say something embarrassing.”
The thoughts lead to feelings of anxiety, fear, or embarrassment.
The mood state triggers physical sensations such as a racing heart, sweating, and shaking.
To cope with these feelings and sensations, the person avoids social situations entirely, reinforcing the negative thought patterns.
CBT can help individuals identify and challenge their negative thoughts and develop alternative, balanced, and often more-realistic perspectives (thinking, for example, “Some people might find what I have to say interesting” or “It’s OK to make mistakes”). At the same time, CBT encourages people to gradually challenge themselves by facing triggering social situations, allowing them to experience new thought patterns and behaviors and thereby gain confidence. By addressing the cognitive and behavioral aspects together rather than in isolation, individuals can experience an improvement in their mood and physiological states, ultimately reducing anxiety and enhancing emotional well-being.
So how can managers put these principles into action? We’ve developed a CBT-based approach we call the ARC model, which equips managers to acknowledge, respond, and help change detrimental patterns for employees struggling with poor mental health. Let’s now look at how managers can use our ARC approach to provide effective mental-health first aid.
Acknowledging Poor Mental Health
Managers should start by acknowledging employees’ distress, thereby increasing the individuals’ own awareness of their mood and validating their feelings. If Ahmed signals to Melia (also a composite of people we’ve worked with) that he is aware that something is bothering her, he creates an opportunity for her to open up. So how should he engage further with her about her mental health?
We recommend that managers use a well-established tool (a four-section diagram referred to in CBT as the hot-cross-bun map) to help employees describe the key features of their emotional and mental states. A manager can encourage employees to consider questions in each area privately if they are not comfortable sharing. For example:
Emotions: What am I feeling right now? How would I describe my mood?
Body: What’s happening physiologically? Am I holding tension in my body (clenched jaw, high shoulders)? Am I breathing faster or harder than usual? Is my heart racing?
Thoughts: What is going through my head at the moment? What thoughts am I having? Can I make them stop for a while or is my mind always racing?
Behavior: What am I doing? Why am I doing it? How am I reacting to my thoughts, feelings, or bodily sensations? Am I avoiding anything?
As the exhibit “One Approach to Understanding Behavior” shows, people can consider the connections among the states in any order. Hot-cross-bun maps are helpful in identifying what psychologists call maintenance cycles: patterns of behavior or thinking that fuel emotional distress. By discussing maintenance cycles, managers and employees can begin to recognize when they or someone else may be feeling stuck or repeating unhelpful patterns.
Within the workplace, typical maintenance cycles include:
This is common when experiencing anxiety. Many people worry about making presentations, for example, possibly because of how they will be perceived or because they have a fear of public speaking. Therefore, they may request not to present. In the short term, this alleviates their worry, but over the long term, it perpetuates their anxiety. The next time they have to speak to an audience they will be just as anxious—and often the anxiety, fed by avoidance, is more intense.
Reduction of activity.
This is typical when experiencing depression and low mood. A manager may notice that an employee is not attending team meetings—or is regularly arriving late for work—and is disengaging socially. The maintenance cycle looks like this: An employee feels unappreciated or unfairly treated. The person decides to do less, reinforcing feelings of lethargy and disconnection.
The need to perform at the highest level is associated with anxiety. When we believe that a task must be done perfectly, we might abandon tasks that we realize we cannot finish to that standard. Or we avoid even starting a task for fear of doing a subpar job. We get paralyzed and become even more concerned that only perfection is acceptable.
Ahmed can help Melia break her unhealthy maintenance cycles by creating a safe space and encouraging her to articulate her feelings and thought processes. To increase her comfort, he might apply the principle of “reciprocation,” sharing his own experiences of feeling inadequate or demotivated at work and explaining how avoidance only contributed to that feeling. In doing so, he offers her a lens for seeing that her current struggles could become a self-perpetuating cycle.
Ahmed should not pry beyond what Melia is willing to share. But let’s imagine that Melia is forthcoming and talks about her feelings of inadequacy, the increased tension in her body, negative self-talk about her abilities, and problematic behaviors such as procrastination or disengagement from colleagues. By examining each of these components, Ahmed and Melia can identify the maintenance cycles that are feeding Melia’s distress: For instance, her feelings of being spread too thin might cause thoughts about not being good enough at her job. This might lead her to avoid taking on new responsibilities, which in turn reinforces her negative self-perception and hurts her performance.
Responding to Signs of Emotional Distress
Once a manager has acknowledged that an employee is in mental distress and has identified the maintenance cycles that feed it, the manager should facilitate a conversation about emotional well-being and help the employee recognize the sources of common mental-health issues in addition to the symptoms of them. Although managers do not provide therapy or counseling, they can learn to apply therapeutic relationship skills. The most important of these is empathy, which is a strong guiding principle in building up relationships.
Empathy is not about offering sympathy but rather about being committed to fully understanding someone’s experience. It requires a conscious effort of perspective taking. Empathy can help a person in distress feel less alone and more understood. In initiating a conversation with Melia, Ahmed could say something like, “I can only imagine how difficult it must be to balance your work here with care responsibilities for your mother. That must be incredibly stressful.” In this statement, Ahmed is acknowledging Melia’s distress, validating her feelings, and expressing his understanding of her situation—all of which is a demonstration of empathy.
When Melia speaks, Ahmed should engage in active listening, and by doing so build trust so that she feels heard and understood. Active listening takes effort and practice. Ahmed needs to give Melia his full attention, allowing her to express her thoughts and feelings without interruption, and then reflect back what he’s heard to make sure he understands. For example, he might say, “What I hear you telling me is that you’re feeling overwhelmed and unsure about your ability to meet all your responsibilities. Is that correct?”
As Ahmed responds to Melia, he needs to adopt a nonjudgmental stance: He should be careful not to offer his own opinions but rather accept that Melia’s thoughts and feelings are valid. Suppose Melia admits to feeling like an impostor or doubting her abilities. Even if Ahmed considers her to be a very high performer, he should respond with, “It’s not unusual to feel that way. Many of us have moments of self-doubt, especially when we’re under stress. I can understand why this is what you are experiencing.”
In keeping a nonjudgmental tone, managers reduce the stigma and shame often associated with poor mental health and provide an opportunity to change the narrative and the perception of mental distress at work. Instead of focusing on an employee’s productivity or problems coping, managers can emphasize how the workplace can be a source of support and encouragement for employees through their distress. If enough managers adopt this approach, they may spark a culture shift in the organization.
When managers initiate conversations with employees about their well-being, they can introduce techniques that facilitate and encourage changes to employees’ mental health. One tool is cognitive reframing, a process of replacing unhelpful thoughts with a more realistic and balanced view of a situation. Cognitive reframing can be an excellent tool when employees (and managers) feel stuck. There are three key steps to this process.
First, identify the unhelpful thoughts. For example, suppose Ahmed learns that Melia is resisting the idea of taking a two-week paid leave for eldercare. In his conversations with her, he realizes that she is feeling worried about how time off would affect workflow. In this step, Ahmed’s first task is to help Melia identify anxiety-producing thoughts, such as: “If I go on family leave, no work will get done, and I’ll have so much to do when I return!”
The next step is to evaluate the thoughts. Ahmed should encourage Melia to scrutinize her negative thoughts for evidence that either corroborates or challenges them. This keeps her from automatically accepting the thoughts and being drawn into a cycle of negative worry.
As evidence of her concerns about work not getting done, Melia may point out that she has received no offers of assistance, that colleagues do not work up to her standards, or that other team members are also out on leave. But Ahmed can help her focus on evidence refuting negative thoughts: No one is indispensable; the organization’s success does not solely hinge on her constant presence; her colleagues have demonstrated the ability to produce quality work; and she has gone on leave before without any dent to her overall performance or interruption to her projects.
The final step is to foster an alternative and more realistic perspective. Informed by Ahmed’s evidence, Melia can begin to frame her situation in a different light: “There may be a lot of work to do when I return from a medical leave, but I need and deserve a break, and others are available to support me if I need them to.” Holding on to unhelpful thoughts perpetuates the worry and triggers a maintenance cycle. However, by using cognitive reframing, we can develop an alternative perspective that is much more grounded in reality and allows us to shift our mood.
In addition to cognitive reframing, Ahmed could help Melia use behavioral activation, a tool that spurs change by increasing opportunities to experience joy. This involves deliberately engaging in pleasurable, productive, or social behaviors, all with the aim of activating a positive emotional state. Ahmed might suggest that Melia make time to get outside for a walk during a break, eat lunch with work friends, or block out time in her calendar to finish a report and feel the satisfaction that brings.
Managers can also use the principles of behavioral activation to reconsider an employee’s job responsibilities and duties. Ahmed could steer Melia toward the kind of work that is most intrinsically rewarding to her. For instance, if she enjoys collaborating with others, he might suggest that she take the lead on a team project or participate in a cross-functional team. If she finds satisfaction in evidence-based problem-solving, he could assign her a challenging task that allows her to utilize analytical skills.