post by Emma Gentry (2021 cohort) and Lucy Hitcham (2023 cohort), with commentary from Dr Aislinn Gómez-Bergin
If you have been following the news over the last six months, you will have seen that one of the UK’s largest Employee Assistance Program providers (EAPs) has been in the spotlight for having potentially violated measures that aim to protect people from harm. In an ongoing investigation, Health Assured have been accused of allowing organisational representatives to listen in on ‘confidential’ counselling calls between employees and counsellors, though the CEO denies all allegations. The BBC1,2,3 reports callers were not aware that non-authorised parties were listening in without their consent or knowledge– not least their employer.
Health Assured serves well-known employers in the UK, including NHS trusts, police forces, universities, and many more.
What is an Employee Assistance Program (EAP)?
EAPs typically offer a range of support services to assist employees with their mental and/or physical health. As mentioned in a CIPD report, EAPs are a popular way for employers to offer additional support to their employees in the UK. Health Assured describes the benefits of an EAP on their website:
“The purpose of an Employee Assistance Program (EAP) is to boost productivity and reduce staff absences…it provides people with the tools needed to get mentally healthy. It raises awareness among peers. It even prepares for returning to work more quickly.”
On the surface, EAPs appear to be a win-win situation for employers and employees alike. But to what extent is workplace wellness about returning to work as opposed to returning to health? In his book ‘Sedated’, James Davies discusses how the individual-level view of mental distress is beneficial to modern capitalism and big business, as it supports the buying and selling of more products. Instead, he argues, we should consider the possibility that it is an understandable reaction to wider problems within our society.
It is important that we pay closer attention to the wider ecosystem that may be impacting employees – especially as organisations are increasingly drawn to ‘stand-alone’ solutions.
Potential breaches of ethical frameworks
As well as unethical ‘eavesdropping’ on confidential calls, Health Assured are accused of staffing helplines with untrained staff who were prevented from speaking out on such issues. Prior to this investigation, Health Assured sold its employee assistance services under the premise that it was the only BACP (British Association for Counselling and Psychotherapy) approved provider in the UK. They used their BACP approval as a marketing technique to sell services to organisations. The BACP outlines an ethical framework for practicing counsellors and psychotherapists in the UK to protect clients in their care. Their key principles include:
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- Being trustworthy: honouring the trust placed in the practitioner
- Autonomy: respect for the client’s right to be self-governing
- Beneficence: a commitment to promoting the client’s well-being
- Non-maleficence: a commitment to avoiding harm to the client
- Justice: the fair and impartial treatment of all clients and the provision of adequate services
- Self-respect: fostering the practitioner’s self-knowledge, integrity and care for the self
Health Assured were held to a certain standard which they did not meet, which has resulted in a suspension of their accreditation. Until we know the outcomes and implications of this case, we can meanwhile consider: what are the key issues here, and what might the future hold for mental health and well-being applications in the UK?
What are the benefits of EAPs and to whom?
Employee Assistance Programs are typically marketed to employers based on return on investment (ROI) metrics – that is, the extent to which investments in those services could pay off. But let’s ask: what are the benefits, and to whom? National EAPs exist first and foremost to make a profit, with many of those who access their triage services signposted to self-help services (to meet certain targets), and few accessing in-person counselling (the most costly part to the EAPs themselves). Why is this problematic at a large scale? A recent study found that those who engage in individual-level wellness schemes at work are not better off than those who do not engage. To add to the picture, there exist conflicts of interest, with mental health and well-being apps often funding research into the effectiveness of their own offerings, similar to how drug companies fund research into their products.
What are the wider risks and to whom?
Health Assured exists within the exponential growth of products and services for mental health and well-being, with vendors leveraging a wide range of marketing techniques to sell their products. Applications – beyond the scope of just the workplace – may risk selling overly simplistic views of mental distress, easily remediated through technology-based offerings. Researchers in the US mapped the APA (American Psychological Association’s) ethical framework against apps for mental health. They found evidence of users experiencing distress, feeling deceived by marketing tactics, and feeling undeserving of support across customer reviews. Another platform, BetterHelp, was recently handed a $7.8m (£6.1m) fine in the US last year after deceiving customers and selling data to third parties. While this occurred in the US, there is a growing need for regulation here in the UK as well.
But let’s consider: why might people use employer-sponsored support as opposed to going through the NHS?
If we look at the wider picture, it can take around 6 weeks, and sometimes longer, for service users to have a first talking therapy appointment. Employer-sponsored services may include shorter wait times and easier access due to the privatised nature of these services. Over the course of the pandemic, we also observed an increase in those accessing digital mental health tools more generally. So, there is a clear desire for support, which these products attempt to remediate. But how much power, choice, and control do individuals have in how they receive support?
In my research (Emma) on the ethics of workplace wellness platforms, the wider issue here could stem from an ongoing disconnect between (1) how diverse individuals experience well-being, (2) conceptualisations of well-being as communicated through design features, (3) the meaning attributed to well-being, and (4) for whom that meaning serves a purpose. I would argue there are wider issues at stake, such as how can employees meaningfully consent to workplace well-being technologies? How much power do employees have in these decisions, and to what extent might the absence of employee voice in the matter backfire on their well-being?
Working Towards a Better Future
While perhaps the most obvious solution is regulation, this is far from straightforward. Alongside the boom in digital mental health tools, there have been increased attempts in the UK to develop regulations from bodies such as the NHS, MHRA and NICE but these are not all legally binding and leave room for grey areas.
Recently, the MHRA and NICE launched a three-year project, funded by the Wellcome Trust, into the regulation and evaluation of digital mental health tools. By working with experts across industries, they aim to comprehensively evaluate the potential risks and benefits of digital mental health technologies (DMHTs) to enable access to safe and effective tools. Part of their research has shown that the public were in favour of DMHTs but either assumed such tools were already regulated or that regulation of apps was the ‘wild west’ and did not pose much risk. Despite this, many supported regulation if this did not restrict access to DMHTs. Therefore, it is important to remember that those developing, regulating and contracting DMHTs hold a significant position of power over users and should consider their duty of care, as I have found in my research (Lucy). This includes making sure that regulation and responsible research and innovation (RRI) are not just “tick box” exercises and companies like Health Assured maintain ethical standards for their services and products.
Dr Aislinn Gómez-Bergin, Transition Assistant Professor in digital mental health, discusses the wider landscape surrounding EAPs:
“The reality is that, in the UK, there is no law requiring therapists or therapy providers to adhere to any standards or qualifications. Membership bodies that do provide a set of professional standards, such as BACP, are voluntary and so limited in what they can do when those standards are breached. You might ask, what is preventing this sector from becoming a free for all? In many cases these companies may wish to adopt principles of doing good or, as with Google, “don’t be evil”. The question then is, how do they decide and who decides what is good? In the case of Health Assured, they had voluntarily signed up to BACP accreditation (although they did not adhere to their standards) and made what proved to be a rather foolish decision to encourage more business through breaking confidentiality.
Clearly, a sustainable business model is an important consideration for employers, who pay for these services, and for users who rely on their mental health support. The problem arises from not anticipating and reflecting on the unintended consequences of their actions. The impact? Avoidable damage to their reputation from a BBC exposé and potential fines if found to have breached data protection rules.
Taking a responsible research and innovation approach when considering what is good, these unintended consequences are explored and actions are taken to mitigate or prevent them; it takes a wider perspective than what a company might be tempted to take (i.e., focusing on those paying for the service and thereby creating a disconnect between consumer and user), allows for more voices to be considered, and can help a company understand not just the socio-technical consequences but also the legal.”
On a final note
Digital mental health continues to revolutionise our world today, and we are likely to see further transformation as AI becomes more sophisticated; however, it is important that we continue to embrace the potential of technology responsibly. While EAPs have been portrayed in a negative light this year, it is important to remember that many calls are handled successfully and sensitively. Utilising a Responsible Research and Innovation (RRI) approach may be more about upholding the reputation of safe and effective services whilst re-establishing public trust in psychological services more broadly. The right support can be transformative for people and our society – we must work together to protect that.