Executive summary
The obligation an employer owes the people who work for it has been widening for a decade, from physical safety toward psychological health, and the published record of that shift is not ambiguous: the World Health Organization counts 12 billion working days lost every year to depression and anxiety, at a cost near one trillion US dollars in lost productivity.04 What has not widened at the same pace is who the resulting programs actually reach. This paper describes the landscape as its primary sources describe it. CEREVITY provides no legal service and no legal opinion, and nothing here is legal advice.
Senior leaders carry the organization's risk, are the most visible people inside it, and are therefore the least able to use a benefit that routes through their own employer.
Programs designed for volume assume an anonymity the leadership tier does not have, and 46% of US workers already say they would worry about losing their job if they talked about mental health at work.20
Fund a clinical route that sits outside the organization's own record, at a depth that matches the problem, and measure whether the leadership tier uses it.
Strain surfaces while it is still a scheduling question, rather than after it has become a resignation, an error, or a medical leave.
The problemThe duty widened. The programs did not.§
The statutory language most often cited as the American employer's baseline obligation is Section 5(a)(1) of the Occupational Safety and Health Act, which requires each employer to furnish employment and a place of employment "free from recognized hazards that are causing or are likely to cause death or serious physical harm."02 The words on the page are about physical harm. The agency's own published guidance is not. OSHA's workplace stress material states that nearly one in five US adults live with a mental illness, that approximately 65% of US workers surveyed characterize work as a significant source of stress, and that workplace stress has been reported to cause 120,000 deaths in the United States each year.01 Prevalence data from the National Institute of Mental Health puts any mental illness at 23.1% of US adults in 2022, with 50.6% of that group receiving any mental health treatment in the previous year.19
The distance between the statutory text and the published guidance is where most employer programs now sit. An employer builds something, announces it, and counts enrollment. The Surgeon General's framework reported that 76% of US workers had experienced at least one symptom of a mental health condition and that 84% named at least one workplace factor that had harmed their mental health.03 Those figures describe a workforce. They do not describe the people who approve the program, and the leadership tier is systematically absent from the evidence base employers use to design one.
A system that incentivizes people to remain silent will cause pilots/controllers to avoid seeking help, leading to unacceptable safety risks. Mental Health and Aviation Medical Clearances ARC, FAA, April 202416
The evidenceWhat the research shows§
Four bodies of published data bear on this question: prevalence across the general workforce, prevalence and concealment inside specific licensed professions, the cost side that employers already track, and the short list of instruments that actually create an obligation. They agree on direction and disagree on almost nothing except how much of it is enforceable. The cost side is better documented than most employers assume, and the cost of presenteeism is where the largest share of it quietly lands.
76%
US workers reporting at least one symptom of a mental health condition
Mind Share Partners, in the Surgeon General's framework, 2022
1.9x
Burnout among health workers who reported workplace harassment, against those who did not
CDC Vital Signs, Quality of Worklife survey, 2023
$15k
Employer cost per year for each employee experiencing a mental health issue
National Safety Council and NORC, 2021
12bn
Working days lost worldwide each year to depression and anxiety
World Health Organization, 2024
Read together, the pattern is not that leaders are worse off than the workforce. It is that workforce data gets collected while leadership data does not, and that the mechanisms built to close the gap stop working exactly where visibility is highest. Gallup's 2026 global report put employee engagement at 20% and manager engagement at 22%, down from 31% in 2022, and recorded managers reporting materially higher stress, anger, sadness and loneliness than individual contributors.12 Deloitte's 2023 study of 3,150 executives, managers and employees found 75% of C-suite respondents seriously considering leaving for a role that better supported their wellbeing, while more than three in four executives believed, incorrectly, that their workforce's wellbeing had improved.13 Utilization is the other half of the problem, and the structural reasons an internal program goes unused by the people at the top are set out in this comparison of employee assistance programs and private therapy.
09, 14, 19, 20 Mind Share Partners. (2025). 2025 Mental Health at Work Report, n=1,153 full-time US workers.
CDC. (2023). Vital Signs: Health Worker Mental Health, Quality of Worklife survey, 2018 and 2022.
American Medical Association. (2025). Organizational Biopsy, nearly 19,000 physician responses across 38 states.
Reference rule: National Institute of Mental Health, any mental illness among US adults, 2022.
| Instrument | What it addresses | Who it reaches | What its own text does not do |
|---|---|---|---|
| OSH Act, Section 5(a)(1) | Recognized hazards causing or likely to cause death or serious physical harm | Employers covered by the OSH Act | Names no psychosocial hazard and sets no mental health standard02 |
| OSHA workplace stress guidance | Work-related stress, burnout, and their effect on performance and safety | Published for all employers as guidance | Is guidance rather than a promulgated standard01 |
| ADA, as enforced by the EEOC | Discrimination, reasonable accommodation, and confidentiality of medical information | Employees with a condition that substantially limits a major life activity | Does not require an employer to build or fund a care pathway05 |
| FMLA, Fact Sheet 28O | Job-protected leave for a serious mental health condition, and confidential medical files | Eligible employees of covered employers | Is unpaid leave, and it provides no treatment06 |
| ISO 45003:2021 | Managing psychosocial risk inside an occupational health and safety management system | Organizations of any size or sector that choose to adopt it | Is voluntary guidance and is not law in any jurisdiction07 |
| Safe Work Australia model WHS regulations | A positive duty to prevent exposure to psychosocial hazards, with a code of practice | Australian jurisdictions that adopt the model laws | Has no application to United States employers08 |
| WHO guidelines on mental health at work | Organizational interventions that assess and then mitigate workplace risks to mental health | Member states and employers, as recommendation | Carries no enforcement mechanism of its own04 |
09 CDC. (2023). Vital Signs: Health Worker Mental Health. Quality of Worklife survey, 2018 compared with 2022.
Axis framed 0 to 50 percent to hold the smaller harassment measures legible.
The frameworkA model you can name and own§
A named model is useful here for a practical reason. Employers already have language for physical risk, and none for the way a psychological benefit fails at the top of an org chart. Without a name, the failure reads as a personal choice by an individual leader rather than as a predictable property of the program. The model below describes four stages, and the point of naming them is that stages two and three are the ones an employer can act on.
CEREVITY model
The Duty of Care Coverage Gap
A four-stage description of how a stated duty of care thins out as seniority rises. Coverage on paper does not change. What changes is what using the coverage would cost the person using it, and each stage names something an employer can observe.
Provision
The program exists, names every employee, and reports a coverage figure. Nothing in the policy excludes the leadership tier, which is why the gap is invisible at this stage.
Exposure
Using the program becomes legible to the organization. A calendar entry, an authorization, a benefits record or a credentialing question turns care into information that other people can read.
Withdrawal
The leader routes around the program. They pay privately, they postpone, or they do nothing. Utilization data records this as an absence of need rather than as an avoided cost.
Discovery
The strain surfaces as an event: a resignation, a leave, a safety finding, a decision nobody can explain. It is now visible to everyone and considerably harder to treat than it was two stages earlier.
SCHEMATIC Schematic, not measured data.
Illustrative model. The stage names and the shape are CEREVITY's; the underlying observations about disclosure, visibility and withdrawal are drawn from the sources cited in sections 02 and 04.
Everything that matters happens at Exposure. An employer cannot legislate away the visibility that comes with rank, but it can decide whether using care generates a record inside its own systems. That single design choice determines whether the Withdrawal stage happens at all, and it is also the point at which the clinical problem and the governance problem become the same problem. The isolation that makes a senior leader unwilling to be seen seeking help is itself treatable, which is the subject of therapy for leadership isolation.
By professionHow it presents across roles§
The gap is not uniform. It is widest in professions where a licensing body, a credentialing committee or a regulator can read the same record the employer can, because in those settings the cost of being seen seeking care is not reputational alone. Three sectors show the pattern most clearly in published data.
Physicians and health system leaders
Medicine has the best documentation of this problem and the longest history of producing it. The CDC's Quality of Worklife comparison found health workers reporting burnout often or very often rose from 32% in 2018 to 46% in 2022, harassment at work more than doubled from 6% to 13%, and the share intending to look for a new job rose from 33% to 44%. Among health workers who reported harassment, 81% reported burnout and 85% reported anxiety, against 42% and 53% of those who did not.09 The AMA's own tracking shows the aggregate improving, with at least one burnout symptom reported by 48.2% of physicians in 2023, 43.2% in 2024 and 41.9% in 2025 across nearly 19,000 responses.14 The cost side is quantified too: a 2019 cost-consequence analysis in the Annals of Internal Medicine estimated roughly $4.6 billion a year in burnout-attributable cost nationally, about $7,600 per employed physician per year, driven by turnover and reduced clinical hours.15 The structural barrier is specific and fixable. Credentialing and licensure applications that ask about prior psychiatric treatment convert care into a disclosable event, and the campaign to remove those questions now reports 74 licensure boards and 3,392 facilities changed, covering roughly 3.35 million health workers.18 That is meaningful progress and it is not universal, which is why physician leaders in unchanged systems still weigh a clinical decision against a licensing one.
Individual physician mental health care
Organizational physician burnout support for health systems
Law firm partners and general counsel
The legal profession's baseline data is older but unusually direct about why people do not seek help. The ABA and Hazelden Betty Ford study of 12,825 licensed attorneys across 19 states found 21% scoring at a level consistent with problematic drinking, rising to 32% among attorneys aged 30 or younger, and 28%, 19% and 23% reporting mild or higher levels of depression, anxiety and stress respectively. Only 7% had sought help for substance use and 37% for mental health concerns, and the barriers respondents named, in order, were not wanting others to find out, confidentiality, and the effect on their license.17 Those three barriers are not clinical. They are informational, and they describe exactly what an internal benefit cannot solve. For equity partners the exposure compounds: the person is an owner of the firm, their utilization runs through a plan the firm administers, and the people who would see any record are the same people who vote on compensation. General counsel sit in a related position, carrying the organization's legal risk while reporting to the executives whose decisions create it. In both roles, the practical question is not whether care exists but whether using it produces a document. Where the answer is yes, the Withdrawal stage of the model above is the predictable outcome, and it will show up in the utilization report as low need.
Individual confidential therapy for lawyers
Organizational an EAP alternative built for law firms
Airline pilots and flight operations leaders
Aviation is the clearest case because the regulator has published its own diagnosis. The FAA's Mental Health and Aviation Medical Clearances Aviation Rulemaking Committee reported in April 2024 that the initial disqualification rate for all mental health diagnoses is approximately 20%, while only about 0.1% of applicants who disclose a health issue and complete the process are ultimately denied a medical certificate. The committee grouped the barriers it found into seven categories, culture, trust, fear, stigma, financial, process, and knowledge gaps, and made 24 recommendations including a non-punitive disclosure pathway and expanded peer support. Its own summary of the risk is quoted in section 01 of this paper.16 The gap between a 20% temporary disqualification rate and a 0.1% final denial rate is the whole problem in one line: the deterrent is the interruption, not the outcome. A captain weighing several months off the line against an untreated condition is making an economic calculation, and flight operations leaders and chief pilots face the same calculation with the added weight of setting an example. Employers in this sector cannot change the certification rules. They can change whether routine, non-reportable clinical work is available, affordable and separate from the company's own records, which is the part of the problem that sits inside their control.
Individual pilot mental health care
Organizational a pilot mental health partnership for airlines
The stakesThe cost of inaction§
The cost of doing nothing is already on the books; it is simply filed under other headings. Three categories capture most of it, and all three are measured by organizations that have no interest in selling therapy.
Lost days and degraded output
The National Safety Council and NORC put the employer cost of one employee experiencing a mental health issue at more than $15,000 a year, of which $4,783 is missed and reduced work and roughly $3,000 is health care spend above that of peers.10 At the population scale the WHO figure is 12 billion working days lost annually to depression and anxiety.04 Neither number counts the hours a leader spends present but unable to decide.
Replacement at the top
Gallup puts the cost of replacing an individual employee at one-half to two times annual salary, and found 52% of voluntarily exiting employees saying their manager or organization could have done something to prevent it.11 Applied to a leadership salary the multiplier does the damage. In medicine the equivalent figure is measured directly at about $7,600 per employed physician per year in burnout-attributable cost.15
Safety, judgment and error
OSHA's own guidance reports that workplace stress has been cited as a cause of 120,000 deaths in the United States each year, and that employers see a $4 return for every $1 spent on ordinary mental health concerns.01 The FAA committee stated the safety logic plainly: a system that rewards silence produces avoidance, and avoidance produces risk.16 This is the category that converts a wellbeing line item into a governance question.
10 National Safety Council and NORC at the University of Chicago. (2021). Mental Health Cost Calculator, built on 2015 to 2018 National Surveys on Drug Use and Health.
NSC notes the underlying survey years predate the pandemic, so the figures are likely to understate current cost.
The solutionWhat effective care looks like§
Effective care for this population has three requirements, and none of them is exotic. First, it has to be reachable without generating a record inside the employer's systems, because the Exposure stage is where use collapses. Second, the clinician has to be familiar with the working conditions in question, since a leader who spends the first four sessions explaining what a partnership track or a certification cycle is will not book a fifth. Third, depth has to be adjustable. Some of this work is a weekly rhythm; some of it needs extended 90-minute sessions to reach material that a shorter appointment keeps interrupting; and some of it is better done in a single continuous block, which is what therapy intensives exist for.
CEREVITY is built to those requirements. It is a nationwide network of independent licensed clinicians, matched to the person rather than assigned by rota, delivered by secure video on a private-pay basis, so no diagnosis code and no shared record leaves the room. Most work runs as the standard weekly session, with the extended and intensive formats available when the problem calls for them. The reasoning behind that structure is set out in CEREVITY's clinical approach.
ImplementationHow to put it into practice§
What follows is an operating sequence, not a compliance checklist. It assumes an employer that already runs a workforce mental health program and wants to know whether the leadership tier is inside it.
- 01
Write down which instruments you are actually reading
Table 1 lists the instruments most often cited and what each one's own text says. Establish, in writing, which of them your organization treats as binding, which as guidance, and which it has adopted voluntarily, such as ISO 45003.07 Questions about legal obligation belong with your own counsel; the point of the exercise is to stop the word "duty" doing undefined work in your own documents.
- 02
Measure the tier you left out of the survey
Most engagement instruments either exclude senior leaders or return samples too small to report. Gallup's manager findings suggest that is where the movement is: manager engagement fell from 31% in 2022 to 22% in 2025, a steeper drop than any other group.12 Report the leadership tier separately or accept that you are not measuring it.
- 03
Remove the disclosure penalties you control
Some penalties are regulatory and outside your reach. Many are not. Credentialing questions about prior psychiatric treatment are the clearest example, and 74 licensure boards and 3,392 facilities have now changed them, covering roughly 3.35 million health workers.18 Audit your own forms, benefit workflows and manager scripts for the equivalent.
- 04
Fund a route that produces no internal record
Whatever the internal program covers, budget a separate private-pay route for the leadership tier, and pay for it in a way that does not surface who used it. Then measure the only thing that matters: whether people at that level book. Report the existence and cost of the route to the board, not the identities.
RecommendationsWhere to start§
Clinical
Treat concealment as the presenting problem
By the time a senior leader books, the concealment has usually been running longer than the symptom. The first clinical task is to make the cost of maintaining the performance visible to the person maintaining it, which is where structured therapy for executive burnout starts rather than where it ends.
Clinical
Match depth to the problem, not to the calendar
A leader who can only offer one hour a week is not describing a preference, they are describing a constraint that the format should absorb. Longer single blocks do work that a fragmented weekly hour cannot, and scheduling should follow the clinical need rather than the default slot.
Structural
Separate the benefit from the record
The design question is not how generous the benefit is but what information it creates. A route that leaves no claim, no authorization and no shared file removes the Exposure stage entirely, which is the practical meaning of therapy that leaves no record your employer can see.
Structural
Report leader coverage to the board, in the aggregate
Boards already receive safety and turnover reporting. Add two aggregate lines: whether a confidential route for the leadership tier exists, and what it cost. Neither line identifies anyone, and their absence is itself a finding worth minuting.
FAQCommon questions§
What is an employer's duty of care?
Does duty of care include mental health?
How do employers meet it for executives?
How does private-pay billing work?
How is my privacy protected?
MethodologyHow this paper was built§
Methodology
This paper was assembled in August 2026 from primary and near-primary sources only. The search covered federal agency publications (OSHA, the Department of Labor, the EEOC, the CDC and NIOSH, the FAA, and the National Institute of Mental Health), international bodies (the World Health Organization, the International Organization for Standardization, and Safe Work Australia), peer-reviewed literature indexed through the Annals of Internal Medicine, and large-sample survey work published by professional and research organizations (the American Medical Association, the American Bar Association with the Hazelden Betty Ford Foundation, Gallup, Deloitte with Workplace Intelligence, the National Safety Council with NORC at the University of Chicago, the Dr. Lorna Breen Heroes' Foundation, and Mind Share Partners). Every source cited was opened and read; nothing was cited from a summary alone.
Date ranges vary by necessity. The regulatory instruments in Table 1 are read as published and are current as of August 2026. The prevalence and cost data span 2016 to 2026, because the anchor study for the legal profession remains the 2016 ABA and Hazelden Betty Ford survey of 12,825 attorneys and no comparable replacement has been published. Sample sizes are stated inline wherever the source reports one: 12,825 attorneys; nearly 19,000 physician responses across 106 organizations and 38 states; 3,150 executives, managers and employees in four countries; 1,153 full-time US workers; 263,810 respondents in the Gallup global sample; 26,069 US public health workers in the CDC survey referenced by the Surgeon General's framework.
Four limitations should be read alongside the figures. First, the measures are not interchangeable. "At least one symptom of burnout," "burnout often or very often" and "moderate to severe burnout" are different instruments, and Figure 1 ranks them together only to show that no occupational group sits near the general-population baseline. Second, almost all of the workforce data is self-reported, and self-report understates concealment by construction: the people least willing to disclose to an employer are also the least likely to disclose to a survey. Third, there is no published dataset of senior-leader clinical prevalence at the quality of the physician and attorney datasets, so the leadership argument in this paper rests on adjacent evidence, manager-level engagement and wellbeing data, C-suite intent-to-leave data, and the disclosure-barrier findings in aviation, law and medicine, rather than on direct measurement. Fourth, cost figures built on pre-2020 survey waves, including the NSC and NORC calculator, are described by their own authors as likely to understate current cost.
No CEREVITY internal intake data is used in this paper. Figure 3 is a schematic, labeled as such in its own source line, and encodes no measurement. Finally, and to be explicit: this paper describes a legal and regulatory landscape as its primary sources describe it. CEREVITY provides no legal service and no legal opinion, and nothing here is legal advice.
References
- 01Occupational Safety and Health Administration. Workplace Stress. U.S. Department of Labor. osha.gov
- 02Occupational Safety and Health Administration. Occupational Safety and Health Act of 1970, Section 5: Duties. osha.gov
- 03Office of the U.S. Surgeon General. (2022). The U.S. Surgeon General's Framework for Workplace Mental Health & Well-Being. U.S. Department of Health and Human Services. hhs.gov
- 04World Health Organization. (2024). Mental health at work. Fact sheet. who.int
- 05U.S. Equal Employment Opportunity Commission. Depression, PTSD, & Other Mental Health Conditions in the Workplace: Your Legal Rights. eeoc.gov
- 06U.S. Department of Labor, Wage and Hour Division. Fact Sheet #28O: Mental Health Conditions and the FMLA. dol.gov
- 07International Organization for Standardization. (2021). ISO 45003:2021, Occupational health and safety management, Psychological health and safety at work, Guidelines for managing psychosocial risks. iso.org
- 08Safe Work Australia. New model WHS Regulations and Code of Practice to help prevent psychological harm at work. safeworkaustralia.gov.au
- 09Centers for Disease Control and Prevention. (2023). Vital Signs: Health Worker Mental Health. Quality of Worklife survey, 2018 and 2022. cdc.gov
- 10National Safety Council and NORC at the University of Chicago. (2021). New Mental Health Cost Calculator Shows Why Investing in Mental Health is Good for Business. nsc.org
- 11Gallup. (2019). This Fixable Problem Costs U.S. Businesses $1 Trillion. gallup.com
- 12Gallup. (2026). State of the Global Workplace. n=263,810 respondents surveyed during 2025. gallup.com
- 13Deloitte and Workplace Intelligence. (2023). Advancing workplace well-being. Deloitte Insights. n=3,150 across four countries, fielded March 2023. deloitte.com
- 14American Medical Association. (2025). Physician burnout rate continues to decline, falling to nearly 42%. AMA Organizational Biopsy. ama-assn.org
- 15Han, S., Shanafelt, T. D., Sinsky, C. A., et al. (2019). Estimating the Attributable Cost of Physician Burnout in the United States. Annals of Internal Medicine, 170(11). acpjournals.org
- 16Federal Aviation Administration. (2024). Mental Health & Aviation Medical Clearances Aviation Rulemaking Committee: Final Report, 1 April 2024. faa.gov
- 17National Conference of Bar Examiners. (2016). Wellness and the Legal Profession: Implications of the 2016 Landmark Study on the Prevalence of Substance Use and Mental Health Concerns among U.S. Attorneys. The Bar Examiner. thebarexaminer.ncbex.org
- 18Dr. Lorna Breen Heroes' Foundation. (2026). More Than 3.35 Million Health Workers Now Practice in States and Systems that Support Their Mental Health. drlornabreen.org
- 19National Institute of Mental Health. Mental Illness: statistics on any mental illness and serious mental illness among U.S. adults, 2022. nimh.nih.gov
- 20Mind Share Partners. (2025). 2025 Mental Health at Work Report. n=1,153 full-time US workers. mindsharepartners.org
Licensed Clinical Social Worker
Martha Fernandez, LCSW is Co-Founder of CEREVITY and a Licensed Clinical Social Worker licensed in California, seeing clients by telehealth nationwide through CEREVITY's network of independent licensed clinicians. USC-trained and bilingual in English and Spanish, she works with founders, executives, attorneys and pilots on burnout, anxiety and depression in high performers, on trauma, grief and high-stakes transitions, and on couples and relationship strain under pressure. Her clinical work draws on cognitive behavioral therapy, acceptance and commitment therapy, behavioral activation, and narrative and solution-focused approaches. She is the author of Wired to Burn.
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