The 14 participating BEM managers were 9 women and 5 men (aged between 30 and 60 years) working at companies in the Munich area. Within their area of responsibility, they had between 40 and 14,000 employees and dealt with an average of 95 cases per year. Because no inclusion criteria were set on the participants’ professional background, there was a large variety of previous experience. Some of them took on their role while employed at the HR department, while others held the position of BEM manager parallel to their regular function in another field of work. One of them carried out BEM as her main activity, as part of her work in occupational health care. These differences led BEM managers to differ in the extent to which BEM activities were part of their daily working lives.

The interview guide’s questions focused on the experiences of the BEM managers with mentally ill returnees during the BEM process. The answers to questions (a) and (d) took up most of the conversation and brought up the most content. During the analysis, we were able to identify the overarching themes of facilitators and barriers, which differ for the three actors described and each consist of a pattern of codes or superordinate codes that can be interpreted as attitudes, behaviors or circumstances that influence the process and the outcome either in a positive or negative way (Table 1). The frequency of the corresponding text passages are given in brackets. The most frequent factors are presented below in the text.

Table 1 Facilitators and barriers in the BEM processMentally ill returnees in the BEM process

BEM managers remarkably often reported an attitude characterized by distrust. A considerable proportion of mentally ill returnees seemed to assume that the process was directed against them and reacted accordingly with uncertainty and negative behavior.

“Nothing happens because they are simply of the opinion: ‘No, I feel bullied. I feel like I’m being bullied, I don’t know what, and you just want me out of here anyway’ and stories like that come up. So it’s not always that easy.” (Participant 10)

“They don’t see it as integration, but more as exclusion.” (Participant 14)

This finding goes hand in hand with a lack of openness. Yet openness about one’s own mental illness (and the associated limitations) is an important factor for a successful BEM process, as was repeatedly emphasized by the BEM managers. It makes it easier to find measures and leads to better acceptance among managers and colleagues during RTW.

“And when someone comes in with his illness, it would be important to me that he simply says what his limitations still are, so that we can really find the appropriate measure with which the BEM then tries to make it easier for him to return to work. (…) It doesn’t matter to me which diagnosis is behind it, what he actually had, whether it’s panic attacks or just- The medical stuff doesn’t interest me. I’m really interested in people being open about ‘what can I do again?’” (Participant 9)

It should be briefly noted that many factors were identified during the analysis to condition the openness of returnees. The most important are trusting atmosphere of conversation and a trusting relationship at the workplace.

The role of the employer as responsible “pacemaker”

BEM managers often mentioned how important it was that they were willing to engage in BEM as a process. This included not only the early initiation of the process in view of its relevance, but above all the willingness to proceed patiently and thus give time and space for finding results and development.

“A great wish, of course, would be that the acceptance of the healthy, especially of the decision-makers, would be so great that they would say ‘Ok, uh, I have an employee here who is now suffering from an illness. The healing process takes longer than six weeks, but I am ready to reintegrate him completely’.’” (Participant 5)

A similarly strong impact, albeit in a negative sense, appears to occur if the employer blocks the smooth running of the BEM process, for example by appointing an inexperienced BEM representative. As the law does not clearly define who is to lead the BEM, this task may be assigned to a person who is somewhat or completely unfamiliar with the procedure.

“Because the BEM is carried out by our managers with the particular employee, we simply received several reports from various sides that the BEM is often not of the required quality. Yes, of course, the managers are not trained. It doesn’t have good quality, it is too often terminated early,it doesn’t take place at all. So, it depends a lot on the manager.’” (Participant 9)

How BEM-managers perceive their position

The BEM managers play a special role in our analysis, as they themselves are active in the BEM process and in fact evaluated their own work themselves during interviews. Instead of speaking about supporting attitudes and behaviors, as was done when we gave an account of employer and employee sides, the BEM managers mainly described their actual work, which in part also reflects the understanding they themselves have of their role. For example, they see it as their duty to offer practical support on work-related issues and to provide information. Although mediation and emotional support also play a major role as tasks, there was a clear distinction in terms of the perceived therapist role. This included, on the one hand, the feeling of being wrongly pushed into this role by the returnees and, on the other hand, self-reported helplessness regarding helping employees with mental illness.

“I’m not a psychologist and I can’t do anything about his illness and I can’t help him. I offer support at the work level so that he can plan his return and feel supported, and everything else must be done by his therapists. So it is also important that this is clear from the beginning.” (Participant 3)

The BEM managers find themselves in an area of tension: in the conversation opposite them is a person whose problems need to be addressed, while at the same time, the BEM serves to find solutions that are expected by the employer.

“So you have to be careful not to cross this line, because when employees say, ‘I find the talks with you so good and it does me so much good,’ then I also say, ‘Doing good is one thing, but it also has to lead to a goal. How can the goal be if you only come to me? We must have some kind of solution then.’” (Participant 14).

Knowledge gaps in the context of the BEM process

It became clear that knowledge about BEM and about mental illness function as overarching concepts, as many of the facilitators and barriers found can be subsumed under them. Knowledge seems therefore to be a decisive factor in successful BEM processes. This observation can be made in relation to all three main actors as shown in Fig. 1, in an illustration that is intended to show how knowledge of the objectives and procedures of BEM (in short: “knowledge about BEM”), as well as knowledge about and understanding of (one’s own) mental illness (in short: “knowledge about mental illness”) are linked to the categories given in Table 1. Several facilitators were reported to be reinforced (↑) by knowledge, whereas barriers were reduced (↓). The following describes how selected facilitators and barriers fit into the concept of knowledge or non-knowledge. For reasons of space, not every point can be supported by a quotation.

Fig. 1

How knowledge strengthens facilitators (↑) and reduces barriers (↓) of the BEM process

Mentally ill returnees who do not know what the BEM process is about could have an unrealistic attitude of expectation and show a lack of responsibility.

“There are also employees who really have this mentality that you have to ask them to everything and they don’t have to move in their behavior. Most of the time it is like this that both sides, the company and the employee, are required to move somewhere toward a common point and sometimes it is also the case that the employee says ‘I am sick, I can’t help it. Now please solve my problem’ and then it falters.” (Participant 11).

Such employees might also show mistrust because they likely do not know what to expect.

On the employer side, the level of understanding of the BEM process is also reflected: those who know enough about BEM and what it should achieve are willing to invest in the process and its measures, while in the opposite case, the process tends to be blocked because it seems superfluous.

Third, a BEM manager that is sufficiently familiar with the process can provide more targeted support and information.

However, knowledge and ignorance play a role in relation to BEM per se as well as in relation to mental illness. If returning employees understand their mental illness and its impact on their ability to work, this increases, for example, self-acceptance and the ability to communicate the resulting limitations.

“Sometimes it is a process over the period of time that you have to reassess your self-image, the image of others, what, no, is at all possible and what you would like to be able to achieve, but which is perhaps no longer possible due to the limitations. This is often very noticeable in the psychological area, yes, that of course the question is ‘Does the person see his or her resilience realistically?’” (Participant 3)

A lack of understanding can lead to anxiety and self-stigmatization and a lack of personal responsibility.

On the part of the employer and the BEM manager, the shortage of knowledge about mental illness manifests itself primarily in the fear of contact. Knowledge of mental illness, on the other hand, was described as positive. Not only in terms of a supportive attitude toward the employee but also regarding greater acceptance in the team.

“I think the most important factors are actually to sensitize the employees and the managers to this and to get an understanding of ‘What’s the problem? What does such an illness do to the employee? And how can we support them to prevent this?’ In other words, to prevent these trigger points.” (Participant 11)

Finally, the BEM manager himself or herself benefits from it: whoever is more familiar with what mental illness means can mediate better between the parties involved and provide emotional support.

From inpatient treatment to the BEM process: a rather unexploited opportunity

The theme of knowledge and non-knowledge also influences the BEM process beyond the main stakeholders. The BEM managers reported that they have only a few contacts with psychiatric clinics and treatment providers, and the clinicians there often do not seem to want to be contacted. This is not the case for the BEM managers, who explicitly called for more exchange of information.

“Um, yes, I would find it useful to have such a better connection, so if it is simply the normal doing, um, um, therapist and company connect in this process, then I would consider that very, very useful, but I rather have the feeling that it comes from the other side, um, that it is not so desirable.” (Participant 11)

The participants also expressed the wish for the psychiatric patients should be informed of the background of BEM before they interact with the process for the first time. Some consideration of what the returnee can currently achieve should have also been provided during treatment.