The COVID-19 Iceberg

A biopsychosocial reflection of the impact on sickness absence and the need for vocational rehabilitation.



In this article, I argue that the importance of psychosocial factors associated to return to good health and work, has become ever more apparent due to Covid-19. In fact, the current focus on health and wellbeing in the general population, provides Vocation Rehabilitation (VR) with the opportunity to demonstrate the value it brings to society. Supporting individuals back on their feet, so they can overcome the barriers that might be preventing them from returning to good health and work, seems extremely relevant. My intention is to reflect on some relevant moderating factors, but not to conduct a full review.


The COVID-19 Iceberg.

The image of an iceberg can help us visualise the likely impact of Covid-19 on the working population, and some of the factors associated with an eventual sickness absence episode. Many individuals will be able to maintain resilience and stay in work, but many others are likely to reach a tipping point due to a combination of biopsychosocial circumstances, that would eventually lead to sickness absence.

Baseline health factors and existing stressors

Prior to Covid-19, many individuals were already coping with existing health conditions, disabilities, and life stressors. For example, about 26 million people in the UK are reported to be living with at least one long term condition (LTC), however, only 56% are in work (1).

In addition, baseline reports on the general mental health of the population were already of concern. The Office for National Statistics (ONS) reported that 1 in 10 people were said to be experiencing depressive symptoms prior to Covid, but this number doubled to 1 in 5 adults by June-2020 (2). With presenteeism and ill-health costing £67billion to UK businesses (3), we did not have a good baseline to start with.


Covid-19 and Lockdown 1.0 and 2.0

When lockdown 1.0 took place, the sudden disruption on lifestyles affected the entire population, and we all had to find ways to manage added pressures. For the ones already coping with baseline health conditions and stressors, one can imagine that things only became more difficult.  From a social support perspective, many individuals were unable to access usual sources of practical and emotional support, which are well known buffers of stress, that help maintain psychological resilience (4).

Although Lockdown 2.0 seemed less severe, this situation brought back restrictions on the population, with social, and economic consequences, adding further strain on many.


Ongoing life uncertainty

Our brains dislike uncertainty. In fact, modern life has given us an illusion of 100% certainty on daily live matters. If you want to buy an item, watch a movie, etc, you can read reviews in advance, to increase your perception of certainty. Being unable to plan our daily lives and feeling unable to control our environment, adds to our levels of stress, with the added compounding factor that modern humans seem less able to tolerate uncertainty because of modern life (5).  Most of 2020 has been uncertain, and only recently, the news of a vaccine being a realistic option, might perhaps help people see light at the end of the tunnel. Still, lockdown 3.0 has not been ruled out, and many who are struggling to find ways of coping, could eventually reach breaking point.


Work uncertainty

The changes in working practices have been significant. Many have been shifted to remote work, whilst others have had to adapt to protective equipment in the workplace, and some have been furloughed, or sadly have become unemployed. At every level, the workforce is having to cope with uncertainty. For some, job insecurity could be the main issue, whereas for others uncertainty about choice and perceived level of control about where and how to carry out work activities will be a main concern.


For home workers, the change to remote work has created an opportunity to discuss and embrace flexibility going forward. But currently, the advice is to remain at home, giving little room for control and choice over where work is carried out. Whilst for many, working from home has enabled a positive life and work balance, others have reported struggles around isolation, technology overload, unsuitable workspaces, and a blurred line between personal and work life. All of these factors add to the notion of a growing iceberg, where individual differences and work culture practices could be key moderators of a future sickness absence episode.


Regarding the furloughed scheme, we are acutely aware of the evidence in relation to the overall deconditioning impact that occurs when someone is absent from work (6). Recently, Dame Carol Black (7), spoke of the similarities and risks of the current furloughed scheme in relation to the benefits system in the UK. She pointed out that anxiety and fear of returning to work were real barriers, and that after a period of time (six weeks), it was hard to help people get back into work. In addition to this, many furloughed workers are at risk of losing their jobs, adding a further layer of complexity into the return-to-work process. As the Furlough scheme comes to an end, it is likely that many workers’ functional capacity for work will be affected, not just by an overall deconditioning, but probably by the accumulation of stressors and or other health issues that employees may have faced throughout 2020, with some feeling vulnerable and concerned regarding health and safety measures in their workplace, if unable to work from home.  As such, vocational rehabilitation experts are well placed to support employees in the journey back into work, understanding their unique individual biopsychosocial circumstances, and making a link with the employers to ensure people return to supportive workplaces.


Health concerns

The direct and indirect impacts of Covid-19 are being widely reported in the media. Many community services were disrupted and or suspended, affecting individuals who were already relying on ongoing care. We have also heard about the impact on health-seeking behaviour, and the fact that many have delayed or avoided contacting primary care, due to beliefs around fear of becoming infected or due to guilt of overburdening the National Health Care (NHS) system. The combined impacts of health-seeking behaviour and the availability of and access to essential diagnostic services, are being documented from a morbidity and mortality perspective, with Cancer, Heart Disease, Mental Health and Long-Covid, being some of the key headlines.


As a snapshot, Cancer deaths are projected to rise to anywhere between 7,000 to 18,000 in the next year (8), whilst the British Heart Foundation reported that there have been almost 800 excess deaths in those dying below the age of 65 from heart and circulatory diseases since the pandemic began (9). In addition, the Centre for Mental Health predicted that up to 10 million people (almost 20% of the population) will need either new or additional mental health support as a direct consequence of Covid-19 (10). Equally, the growing evidence on Long-Covid and long-term impact on health, is now taking centre stage in the media, with 1 in 45 reported to continue to experience residual symptoms after 12 weeks, according to the Covid Symptom study (11).  In addition to this, individual’s coping strategies will play a key role, particularly on the use of adaptive versus maladaptive coping. Unfortunately, alcohol intake, smoking, and lack of exercise will likely have a compounding impact too.


Sickness absence and the need for vocational rehabilitation

As we reach the tip of the iceberg, it is only natural to expect that many will unfortunately struggle to stay in work and experience a sickness absence episode. The reasons will likely vary from a combination of medical, psychological and psychosocial factors. Some experiences would be directly related to Covid, but others, as mentioned earlier, will be in relation to the indirect impacts, with added compounding factors associated to a set of pre-existing health circumstances and life stressors. Addressing psychosocial barriers such as beliefs, self-efficacy, coping strategies, job-role modifications, alongside with treatment, if required, can be effective, and VR professionals are well placed to provide the support required to enable the transition back into work for the ones affected.


From a protection insurance perspective, the value of VR is going from strength to strength, particularly in the Group Income Protection (GIP) market, where approaches such as early intervention strategies, and general wellness initiatives targeted at the prevention of sickness absence are having a positive impact.  For instance, in 2019, 3,415 people (34.7% of all claims submitted) were supported back to work before they reached the point of making a claim (13), demonstrating the value in providing rehabilitation and return to work support early in the sickness absence journey. I anticipate that this figure will increase in 2021 with more insurers seeking to provide evidence-based return to work rehabilitation interventions for their income protection customers.


We will need to do more to share the great case stories that highlight the expert support of VR practitioners to wider audiences. I am hopeful that 2021 will bring the opportunity to wider the awareness and applications of VR in other settings, including primary care, government bodies, employer communities, and the private medical insurance sector, where currently VR is not available, unless return to work advice and support is given via a registered allied health professional, through psychotherapy or physiotherapy for example.


Monica Garcia BSc (Hons) Psychology, MSc Health Psychology.

Health and Wellbeing Insurance Consultant


  4. Bailey, Darlyne; Wolfe, Donald M.; and Wolfe, Christopher R. (1994) “With a Little Help from Our Friends: Social Support as a Source of Well-being and of Coping with Stress,” The Journal of Sociology & Social Welfare: Vol. 21 : Iss. 2 , Article 8.
    Available at:
  6. Black, C and Frost D (2011) Health and work an Independent Review of sickness absence: Health at work – an independent review of sickness absence
  7. Furloughed scheme’s effect on health and work (2020) Times letters: Furlough scheme’s effect on health and work
  12. Shaw WS, Main CJ, Findley PA, Collie A, Kristman VL, Gross DP. Opening the Workplace After COVID-19: What Lessons Can be Learned from Return-to-Work Research? [published online ahead of print, 2020 Jun 19]. J Occup Rehabil. 2020;1-