Return to work after a mental breakdown: findings from employees within the South African public service

There is a growing global prevalence of mental health disorders, such as depression, anxiety and stress in the workplace, causing significant challenges for both employees and organizations (de Oliveira et al., 2023). The World Health Organization (2022a, 2022b) defines mental health as a “state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well and contribute to their community^[1]”. This definition highlights the importance of personal capabilities, having an effective coping mechanism (the ability to manage stress and challenges), and making social contributions. When an individual’s mental health is neglected or not attended to, it can cause mental well-being to deteriorate, leading to a mental health crisis, making it difficult to cope with daily activities, which can affect personal relationships and performance in the workplace or school (Mediclinic, 2024; Tawiah et al., 2015).

Mental health disorders, including depression, anxiety and Post Traumatic Stress Disorder (PTSD) (often linked to South Africa’s high rates of trauma and violence; Kaminer and Eagle, 2010), have emerged as a global pandemic and as a critical issue that can significantly interrupt a person’s ability to function both on personal and professional levels. Global estimates reveal that one in every eight people in the world lives with a mental health condition (World Health Organization, 2022b). Approximately 60% of the world’s population is used and an estimated 15% of working-age adults, typically ranging from 18 to 65 years old, experienced a mental disorder in 2019 (World Health Organization and International Labour Organization, 2023). Estimates in South Africa reveal that one-quarter of South African employees will be diagnosed with a mental health disorder during their employment, and approximately only 15%–25% will seek and receive help (Employee Assistance Professionals Association of South Africa, 2023). These statistics highlight the impact mental health has on individuals within the workforce globally and nationally.

The increasing prevalence of mental health challenges is highlighted by designated days and months aimed at promoting mental health awareness, such as World Mental Health Day. In addition, various states have their specific days and months dedicated to fostering mental health awareness. Although there has been a notable increase in focus and awareness surrounding mental health issues, one of the most challenging aspects remains the return-to-work (RTW) process for employees, who experience mental health disorders. Organisations need to address and support mental health in the workplace because mental health disorders in the workplace have enormous consequences, such as low productivity, absenteeism and other indirect costs (World Health Organization, 2022b). When employees’ mental health deteriorates, it can significantly impact their work performance. In such cases, they must take work leave to seek support and focus on their overall mental well-being.

Returning to work after a mental health crisis presents unique challenges for individuals. It is crucial to develop effective strategies to facilitate employees’ RTW after a mental health-related absence. There is limited empirical research in South Africa on understanding the specific challenges that employees face in the process of returning to work after taking leave from work to care for their mental well-being. This article highlights the journey of returning to work after a mental health crisis by looking at the personal experiences of 15 employees working within the South African public service.

In South Africa, mental health disorders are exacerbated by socioeconomic stressors like unemployment and inequality, and historical trauma (Lund et al., 2013). Workplace impacts include a negative impact on employee well-being, which consequently contributes to lost productivity and harms the overall success of the organisation (Beck et al., 2011; de Oliveira et al., 2023; World Health Organization, 2022b). Productivity refers to absenteeism (number of days spent away from work) and presenteeism (being unproductive while at work) (Beck et al., 2011; de Oliveira et al., 2023). There is a positive relationship between mental health disorders and lost productivity in the workplace (Beck et al., 2011; de Oliveira et al., 2023). Individuals struggling with mental health disorders struggle with abilities to perform work-related tasks, which leads to increased absenteeism and presenteeism. In addition, there is a monotonic relationship between mental health disorders and productivity loss; that is, the more severe mental health disorders are, the greater the amount of productivity lost (Beck et al., 2011:309).

Furthermore, mental health disorder in the workplace is positively associated with job performance (Ahmadi et al., 2012; Lu et al., 2022). Mental health disorders affect cognitive functions such as concentration, motivation and drive, which in turn affects overall job performance (Mediclinic, 2024). These functions include concentration, which affects an individual’s ability to focus on tasks; motivation, which influences the drive to accomplish work-related goals; and drive, which impacts overall persistence and determination in the workplace. Employees presenting symptoms of mental health disorders had significantly lower job performance when compared to those with no mental health disorders (Stander et al., 2016).

While mental health challenges result in lost productivity and low job performance, they also lead to economic burdens for individuals and economies around the world. For instance, there is a global estimate of 12 bn working days lost every year due to mental health challenges such as depression and anxiety, resulting in a cost of US$1 tn per year in lost productivity (WHO and ILO, 2023). As reported by Employee Assistance Professionals Association of South Africa (2023), employee absenteeism due to mental health disorders costs the South African economy approximately R19 billion annually.In addition, the economic burden of mental health disorders on individuals includes lost income (Lund et al., 2013) and medical costs.

Returning to the workplace after mental health sick leave is a complex and multifaceted process influenced by various factors such as health factors, personal factors, environmental factors and societal factors.

The severity of mental health disorders has an impact on RTW among employees. Employees undergoing treatment for common mental health disorders are linked to an optimistic likelihood of RTW (Victor et al., 2017). Also, lower severity of an illness is associated with a positive outcome of RTW (Cancelliere et al., 2016). In contrast, employees with a history of psychiatric (chronic) treatment often face difficulties with RTW (Victor et al., 2017). The prevalence of mental health disorders influences RTW outcomes among employees (Cornelius et al., 2011).

Sociodemographic characteristics such as higher education, younger ages and socioeconomic status are positively associated with RTW. In contrast, employees of older ages are associated with negative RTW as they take longer time than younger age groups (Cancelliere et al., 2016; Cornelius et al., 2011). According to Cancelliere et al. (2016), females are associated with negative RTW. However, Cornelius et al. (2011) argue that the gender effect in the process of RTW is inconclusive.

Workplace-related factors such as employer/supervisor support, Employee Assistance Programme , creating an enabling environment, and interpersonal relationships at work are important in facilitating the RTW process (WHO and ILO, 2023). The American Psychiatric Association Foundation (2022:6) states that employers play a key role in the health and well-being of their employees; as a result, they need to develop strategies and approaches focused on enhancing mental health in the workplace.

There has been an increase in mental health awareness in the workplace. However, employees believe that their employer will not know how to support them when dealing with mental health disorders, while managers/employers also alluded to not being sure how to support employees with mental health disorders (Stander et al., 2016); this may cause employees to have difficulties in the RTW process. However, supervisors with personal experience of mental illness tended to demonstrate a remarkable level of compassion and empathy toward employees navigating similar challenges (De Jesus and O’Neil, 2024).

Individuals who live with certain medical conditions, such as mental health, obesity, Human Immunodeficiency Virus (HIV) or disabilities, often encounter stigmatisation and discrimination from society, family and friends (Skinner and Mfecane, 2004; Tawiah et al., 2015). Stigma occurs when an individual is viewed negatively due to their medical condition (mental illness), whereas discrimination happens when someone is mistreated because of their medical condition (mental illness). People living with mental disorders are subjected to internalised and externalised stigma (Egbe et al., 2014). Internalised stigma prevents people with mental illness (PWMI) from seeking help because they are afraid of what others will say or how they will be treated (Egbe et al., 2014; Stander et al., 2016); that is, employees often fear being judged or labelled as “unfit” to perform their roles which may further exacerbate their mental health.

Furthermore, external stigma prevents PWMI from seeking help. PWMI are subjected to stigmatisation, mistreatment, and discrimination from healthcare facilities, families, and communities (Egbe et al., 2014; Kapungwe et al., 2010; Tawiah et al., 2015). The stigma surrounding mental illness is a complex issue which creates a barrier that prevents PWMI from seeking help, resulting in delays in treatment, which can ultimately worsen their quality of life (Ahad et al., 2023; Schoeman and Voges, 2022). Furthermore, stigma and discrimination surrounding mental health disorders have a significant economic, social, emotional and psychological impact on PWMI. It often results in difficulties securing employment, low self-esteem and exacerbated feelings of isolation (Schoeman and Voges, 2022; Tawiah et al., 2015).

A further dimension of mental health challenges relevant to workplace reintegration is the phenomenon of self-stigma. Self-stigma occurs when individuals internalise negative societal stereotypes about mental illness, leading to diminished self-esteem, reduced self-efficacy and behaviours that attempt to counteract anticipated discrimination (Corrigan and Rao, 2012). Such internalisation can have significant consequences for employees returning to work after a mental health crisis. Rather than receiving external stigma alone, individuals may begin to believe that they are less competent, unreliable or undeserving of equal treatment.

Informed by the presented literature, this research was guided by the following research question:

This study used a qualitative research design through narrative inquiry to investigate the experiences of employees returning to work after a mental health crisis. Narrative inquiry was deemed appropriate because it enables the collection of personal stories that reveal how individuals make sense of significant life events, such as taking leave for mental health support and subsequently reintegrating into the workplace. The interview guide was developed by the research team, though it did not involve lived experience advisors in the design process. However, the semi-structured format of the interviews enabled participants to direct the conversation and shape the narratives they shared.

The study recruited participants from five public service entities in the Eastern Cape Province in South Africa. An invitation was sent via email to these organisations, requesting the participation of employees who had undergone psychosocial support to participate in a research interview. The involvement of these organisations was important in recruiting participants to the study. Eligibility criteria included employees who had taken up to three months off work (actual leave duration being 1–5 weeks, with a mean average of 2.7 weeks). Furthermore, the participants must have self-identified as needing mental health support. In addition, they must have received time off from work for a period ranging from 1 week to 12 weeks to seek psychosocial support and must have returned to work after receiving psychosocial support. A total of 15 participants (n = 15) working within the South African public service in the Eastern Cape were successfully recruited. Participants engaged in in-depth interviews, each lasting between 45 and 70 min.

The study had 15 participants (8 females and 7 males). The majority (7) of the sample identified as Black African, six identified as coloured and the rest identified as White and Indian. Participants represented a variety of seniority levels in the workplace. Six participants were in junior-level positions (general workers), five were in middle management and five were supervisors. The tenure of seniority varied between 3 and 11 years, with the average length being approximately 7.5 years. Finally, participants took between 1 and 5 weeks off work, with an average absence of 2.7 weeks, to seek mental health support. Table 1 presents the demographic characteristics of the sampled participants.

The study received ethical approval from the participating university where the researchers are based [Ethical Clearance Number and Awarding Institution Retracted for Anonymity]. In addition, clearance was granted by the relevant public service entities through their human resources departments. Participants were informed about the aim of the study and were informed about the consent before participating in the study. This process adhered to the principles of informed consent and ethical guidelines outlined in the Declaration of Helsinki. Furthermore, as an additional ethical safeguard, participants were provided with contact details for free counselling services (EAP-SA, 2023) and could pause or withdraw anytime. The HR departments are also committed to post-interview support.

Narrative analysis was conducted with the participating public service employees to understand their RTW experience after a period of receiving mental health support. The use of narratives allowed the utility of drawing from the experience of each participating employee, including understanding how the sense-making of this experience happens from the vantage of the individual. The three levels of meaning-making (McCormack, 2000) were used to analyse the data informed by the desire to understand the lived experiences of the participants guided by the research objectives of the study (Chinyamurindi and Rashe, 2021). These three levels allow researchers to be able to understand better each participant’s experience through a rereading of each transcript (Thornhill et al., 2004) and then exploring meaning-making and connecting aspects of what was experienced and how this is interpreted (McCormack, 2000).

Based on the narrative analysis, three main findings emerged from the participant stories detailing the experiences of returning to work after seeking mental health support among public service employees. First, the challenge related to reintegration into the workplace manifests through stigma within the workplace. Second, an excessive individual pressure to want to prove themselves post-return for immediate acceptance. Third, the noted lack of support interventions, especially after returning to work, as compared to support for initial diagnosis of mental health challenges.

Participants expressed that stigma affected their reintegration into the workplace. To the participants, a common issue that affected aspects of reintegration was stigma. This included notable aspects related to a perception of labelling and discrimination. One participant expressed this stigma as caused by perceptions towards mental health in society:

An attribution of the stigma is a lack of frankness around the conversation of a mental health nature. This conversation was deemed important, yet it did not happen to the level that some of the participants felt it should have. This was also succinctly explained by one of the participants in the study:

The views of participants 12 and 15 are also supported by another participant who described experiencing stigma, including what they called “secondary stigma,” mainly affecting coworkers deemed to have an association with this participant:

The issue of stigma is prevailing and affecting the RTW. Table 2 shows additional quotes from participants supporting this narrative and showing the added mental strain this creates post-return to work.

Participants expressed a challenge that comes with returning to work, which consists of pressure to perform as a way of gaining acceptance. One participant narrated this pressure as manifest in a desire to seek for a status that may been perceived to be lost:

One participant expressed this pressure to perform in view of their fears:

The pressure to perform was also framed within a social context; given the prevailing unemployment in South Africa, the pressure to perform was a means to try and make sure that the individual protects themselves fearing being unemployed:

The pressure to perform for acceptance was flagged as part of employee experience post-return to work. Table 3 shows additional quotes from participants supporting this narrative and showing the added mental strain this creates post-return to work. This phenomenon of overcompensation is in line with Goffman’s (1963) concept of “stigma management,” where individuals alter behaviour to mitigate social discrediting.

Participants expressed a challenge that comes with returning to work, which consists of pressure to perform as a way of gaining acceptance. One participant narrated this pressure as manifest in a desire to seek a status that may be perceived to be lost:

One participant also expressed the same challenges:

Other participants felt there is a need more emphasis to be given to not only just talking about the challenges of mental health but also more proactive steps post-diagnosis or after being urged to get help:

There appears to be a lack of targeted focus in terms of interventions related to RTW support. Table 4 shows additional quotes from participants supporting this narrative and showing the added mental strain that creates a post-return to work.

The study examined the experiences of RTW after taking time off to receive support for mental health among 15 public service employees. Societal factors, such as stigma in the workplace, play a significant role in the RTW process. Participants’ experiences highlighted that stigma hinders the process of RTW, with many internalising workplace discrimination, a phenomenon aligning with Goffman’s (1963) theory of stigma as a “spoiled identity.” For example, Participant 3’s fear of secondary “stigma” mirrors Goffman’s observation that stigma “taints” not only the individuals but their associations. These findings have also been confirmed through various research on mental health and stigma in the workplace (Ahad et al., 2023; Egbe et al., 2014; Schoeman and Voges, 2022; Stander et al., 2016). In addition, the results indicated that stigma happens as a result of fear and lack of awareness (WHO and ILO, 2023).

A notable contribution of this study is the identification of “pressure to perform” as a central challenge for employees returning to work after a mental health crisis. Participants reported that they overworked themselves, exceeded normal expectations, and feared being “marked” by their past mental health struggles within their organisations. This pressure can be understood through the concept of self-stigma, where individuals internalise public stereotypes of mental illness and apply them to themselves, often resulting in self-doubt, lowered self-esteem and compensatory behaviours (Corrigan and Rao, 2012). In this context, self-stigma resulted in participants feeling an intensified need to prove their competence, which paradoxically added to their stress and hindered their recovery.

Furthermore, environmental factors such as supervisor support and the creation of a conducive working environment play a crucial role in facilitating reintegration into the workplace (American Psychiatric Association Foundation, 2022; WHO and ILO, 2023). Participants expressed concerns about the lack of support following their RTW after taking time off. This aligns with other research highlighting employers’ inadequate support for employees with mental health disorders (De Jesus and O’Neil, 2024; Stander et al., 2016). Lack of support was also evident in the pressure participants felt to perform to gain acceptance rather than having employers accommodate their return by reducing work hours and workload.

Study findings suggest that workplace mental health policies primarily focus on the initial diagnosis and leave-taking process but fail to address the post-return phase, leaving employees without adequate reintegration support. Therefore, the study suggests the need for public service organisations to formulate comprehensive mental health policies that foster workplace inclusivity and provide structured support for employees returning to work after mental health challenges. Employers should focus not only on providing initial care but also on offering ongoing support, such as adjusting workloads, providing counselling and maintaining open lines of communication between management and employees (American Psychiatric Association Foundation, 2022).

Policy changes should also target mental health stigma in the workplace. Creating anti-stigma programs and training managers to be more empathetic towards mental health issues can help employees feel more supported upon their return (De Jesus and O’Neil, 2024).

The study reveals that employees often feel the pressure to prove themselves after a mental health-related absence, which can result in overcompensation and burnout. To mitigate this, employers should introduce gradual reintegration plans that allow employees to RTW on a part-time basis or with modified duties until they feel ready to resume full responsibilities (Stander et al., 2016). Therefore, organisations should develop RTW programs and clear frameworks for managing mental health challenges in the workplace.

Moreover, the creation of a supportive work environment is essential. The study points out that employees often feel isolated or stigmatised upon their return, making them less likely to engage fully in their work. Therefore, a focus on workplace culture change – fostering an open, supportive and nonjudgmental environment could significantly ease the transition process (Ahad et al., 2023).

One limitation of the study is its relatively small sample size, consisting of only 15 participants. In addition, the research is geographically focused on the Eastern Cape Province in South Africa. This regional concentration may restrict the applicability of the findings, as the experiences of employees in other regions or industries could vary significantly. Future studies should include more extensive and diverse samples from different regions and sectors to increase external validity (Cornelius et al., 2011). Furthermore, future research should investigate the long-term effects of RTW programs on employees’ job satisfaction, productivity, and mental well-being. Specifically, studies could focus on how the duration and quality of post-RTW support impact long-term reintegration success. In addition, it would be valuable to explore whether employees who receive tailored support experience higher job satisfaction and lower absenteeism rates in the years after their return.

Finally, another limitation of the study was the absence of direct involvement of individuals with lived experience of mental health crises in the study’s design or data analysis. Future research could benefit from adopting participatory or co-production approaches to ensure that the perspectives of those with lived experiences inform the design and data collection processes.

This study highlighted the challenges that employees face when RTW after taking time off to seek mental health support. The results highlighted two factors (societal and environmental) that significantly hinder the process of RTW for employees in public service. These results suggest that employers need to put effort into creating interventions that support and promote mental health in their organisations; employers can help ease the RTW process and contribute to a healthier workplace environment.