Lesson from Taiwan: treating workplace mental illness on par with physical injuries
1. Introduction 
 
As an oft-quoted statement by Dr Brock Chisholm, the first Director-General of the World Health Organisation, reads, “without mental health there can be no true physical health”, it has become increasingly clear nowadays that mental health has become an equally cardinal part of health like physical well-being. However, policies and laws surrounding the said subject are often sluggish when it comes to responding to the increasing emphasis on people's actual and imminent needs of mental health, resulting in a mental health crisis that prevails in the workplaces across different countries. Particularly, Asian countries are notorious for having employees work long hours, exacerbating the mental health issues of the already stress-stricken workers. Mental illnesses induced by workplace risk factors, such as long working hours, confrontation with colleagues, and demanding workload, are often brushed aside in that mental health problems are commonly misunderstood as results of personality weaknesses or character flaws.
 
Unlike physical injuries where signs and wounds are easily discoverable, mental illness can be hardly noticeable until the harm manifests with pernicious effects on one’s physical health. In more extreme cases, chronic and unresolved stress and burnout could even push one to the brink of death. Despite the importance of mental wellness of workers, employers often overlook their employees’ mental wellbeing. Nonetheless, the lack of a comprehensive legal regime to acknowledge and compensate for employees’ mental ill-health is another contributing factor to deteriorating mental health in the workplace. Without a legal occupational health safety framework that takes into account the mental health of employees, workers hardly have any legal redress should any psychological harm emerges in the workplace.
 
2. The Regulation and Guidelines
 
Taiwan is one of the few countries which recognises mental illnesses as an occupational disease legally [1]. The Labour of Taiwan Council of Labour Affairs (“CLA”) (was later restructured as the Ministry of Labour today) in 2009 officially added article 21-1 to the “Regulation on the Criteria for Identifying Occupational Injuries” (the “Regulation”) (「勞工保險被保險人因執行職務而致傷病審查準則」), which characterises mental illness as a compensable occupational disease under work insurance coverage, provided that a substantial linkage between work and the resulted harm is established:- 
 
“The insured person is considered to have an occupational disease if he/she suffers from a mental illness that is substantially related to the performance of his/her duties.” 
 
In addition to the “Regulation”, CLA published more specific and detailed “Guidelines for the Identification of Mental Illnesses Caused by Work-Related Stress Events” (the “Guidelines”) (「工作相關心理壓力事件引起精神疾病認定參考指引」) to inform medical practitioners and the Administrative branch on how to evaluate the work-relatedness of a person’s mental health problems. In essence, a work-related stressful event is considered to be the cause of the mental illness if all three of the following are satisfied:
 
1. the onset of the target disease (i.e., any of the diagnosed episodes in F2 to F9 of ICD-10) 目標疾病發病。(即ICD-10的F2至F9中任一診斷發病)
2. a strong psychological burden arising from the business can be recognised for approximately 6 months prior to the onset of the target disease在目標疾病發病前約6個月內,可認定有業務造成的強烈心理負荷
3. no "out-of-business psychological strain" or "personal factors" could be identified as the cause of the onset of the target disease無法認定因「業務之外的心理負荷」或「個人因素」造成目標疾病發病
 
Insofar as a “strong” psychological burden is concerned, specific reference is made to a set of factors as stipulated in the Guidelines [2]: 
 
(i) An accident or disaster, e.g., (serious) illness or injury; experiencing or witnessing a tragic accident or disaster
(ii) Work failure and excessive burden, e.g., being held responsible for accidents and incidents that take place in the company, being forced to do illegal business-related acts, being given unachievable business benchmarks
(iii) Quantity and quality of work, e.g., a significant increase in workload and overtime hours, as well as a substantial change of work content
(iv) Change in role or status, e.g., unreasonable dismissal, position transfer or relocation of the workplace, differential treatment, demotion or promotion 
(v) Interpersonal relationships at work, e.g., being subjected to harassment, bullying or violence, disputes with supervisors and colleagues 
(vi) Sexual harassment 
 
It is only when workplace stressors are translated into legally binding guidelines will workers’ mental wellness be properly addressed. As Taiwan has demonstrated, factors that one deems hard to objectively evaluate can be realistically adapted into a legislative framework in the context of assessing stress claims for compensation. Although a preventative approach, (such as education and health promotion strategies) still carries significant weight in promoting the mental wellness of employees in workplaces, it is about time to rethink whether a legal approach, which gives due consideration to workers’ plight from a mental health perspective and provides redress accordingly, should also deserve a heightened priority because workplace-related/induced stress and burnout among employees are not uncommon to date.
 
3. Milestone Cases
 
The promulgation of the Regulation and the Guidelines in 2009 is a significant step forward to protecting labour rights. Following the announcement of the said legislation, CLA’s decision not to recognise depression as an occupation disease was reversed. In the case of 燿華電子公司陳巧蓮 (CHEN Qiao-lian of Unitech Electronics Co.), CHEN, an operator at Unitech Electronics Co, was subjected to unwarranted demotion and abusive language, which subsequently caused her to suffer from depression in 2007. It was only after 2009 that CLA recognised her case as being suitable for claiming compensation under the “Regulation on the Criteria for Identifying Occupational Injuries.”
 
Three years after came another hallmark case of 台塑六輕廠監工張倍逢 (CHANG Pei-fong of Formosa Plastic Group) in 2012, where stress-induced suicide was recognised by the then Labour of Taiwan Council of Labour Affairs (勞委會) as an occupational disease. CLA ruled that CHANG’s suicide was attributed to his unstable mental state arising from persistent work pressure and overtime work. Despite the absence of a written ruling from CLA, news sources suggested CHANG had been deeply concerned about the spate of industrial accidents in the factory complex. CHANG had liaised repeatedly with contractors and supervisor in a bid to improving occupational safety but to no avail. With his concerns unheeded, his suicide sadly struck. The case is significant for it demonstrated the readiness of CLA to recognise stress-induced suicide, notwithstanding that it is barely possible for doctors to trace the relevant clinical history of mental ill-health “for approximately 6 months prior to the onset of the target disease.”
 
The above are good cases in point illustrating the application of the Guidelines. That said, the percentage of cases of mental illness being recognised as an occupational disease remains low since the promulgation of the detailed Guidelines in 2009. From 2016 to 2020, out of a total of 94 cases filed over the five years, only 29 cases, representing 30% of the total number of cases, were ruled by CLA as an occupational disease, thereby entitling claimants to insurance compensation under the Labour Insurance Act [3].
 
Table 1: Psychological Occupational Disease in Taiwan (2016-2020) [4]

Type

Time

Number

Psychological Occupational Disease in Taiwan (2016-2020)

Cases Filed

2016

19

2017

19

2018

16

2019

29

2020

(Jan-June)

11

Psychological Occupational Disease in Taiwan (2016-2020)

Cases Recognised as Occupational Disease

2016

6

2017

6

2018

3

2019

8

2020

(Jan-June)

6

 
For a long time, there appears to be no room for discussion for recognising mental illness as an occupational disease on the premises of its multifactorial nature.  The passage of the Regulation and the Guidelines discussed above indeed shows an advanced move of the Taiwanese government to promote mental wellness in the workplace. Yet, the figures are telling in that they rightly indicate, that in practice, the entire policy and legal regime is almost left idle as evidenced by the slim successful rate of claims.  While numerous stressful events have been included the Guidelines as the relevant factors for the assessment of insurance compensation claims, the application of the Guidelines remains one of the biggest challenges of the current labour protection laws and regulations. 
 
More importantly, mental health at work is definitely not an issue limited to Taiwan only, but rather a crucial issue to the Asian region, and even to the global world. Regrettably, the issue is not yet on the agenda of trade unions and labour groups in many places, and not yet on the agenda of the International Labour Organization, either. There is a long way for workers to fight for their rights to mental well-beings.
 
Notes:
[1] For example, Korea and Japan.
[2] 工作相關心理壓力事件引起精神疾病認定參考指引, Annex I
[3] Labour Insurance Act, s 34
[4] Data from the Bureau of Labour Insurance, Ministry of Labour
 
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