CBT for Occupational Stress in Health Professionals

Introducing a Schema-Focused Approach

Martin R. Bamber

• Éditeur: Routledge
• Année: 2006
• ISBN:
  9781135446611
• Édition: 1
• Sujet: Politique et relations internationales
• Sous-sujet: Politique sociale

The costs of occupational stress in terms of sickness absence, ill-health-related retirement, litigation and lost productivity are increasing, putting strain on economies across the world. The fact that health care work is inherently more stressful than many other occupations makes it vital that the problem of occupational stress among health professionals is addressed.

CBT for Occupational Stress in Health Professionals goes beyond simply defining the problem and fills a gap in the current literature by providing clear and concise individual treatment interventions. In three parts, the book covers:

• an overview of stress in the occupational context
• the standard CBT approach to assessment, formulation and treatment
• a new schema-focused approach to treating occupational stress.

The schema-focused approach presented here provides powerful tools for treating a range of work-related problems for which standard CBT approaches are ineffective. Case studies are presented throughout the book to illustrate the therapeutic approaches described.

This book will be of huge benefit to clinical and organizational psychologists, psychiatrists, mental health workers, counsellors and anyone else involved in treating occupational stress. It will also have much to offer those who manage people suffering from stress, human resource workers and those who are experiencing work-related stress.

Part 1
Introduction

Chapter 1
Defining and conceptualizing stress

Martin Bamber

I know there is no happiness for man except in pleasure and enjoyment while he lives. And when man eats and drinks and finds happiness in his work, this is a gift from God.

(Book of Ecclesiastes Chapter 3: 1–14)

INTRODUCTION

One consequence of the evolution to a more global economy is that as the competition for market share and survival increases, pressure mounts on workers to become ever more productive (Hoel et al. 2001). Occupational stress is an unfortunate consequence of this, affecting a growing number of people across the world (Cox et al. 2000). It is estimated that up to 40% of all sickness absence from work is due to stress (Confederation of British Industry [CBI] 2000; Hoel et al. 2001). In the UK alone this is costing employers and health insurance companies billions of pounds each year in lost productivity and health insurance claims (CBI 2000; Gordon and Risley 1999). However, the costs of stress in organizational terms are much broader than just those incurred through sickness absence. They include increased staff turnover, recruitment problems, low morale in staff, decreased productivity, poor time-keeping, impaired decision-making, increased industrial conflicts, increased accident rates, premature ill-health retirement, and costs related to redeployment, retraining, replacement, grievance procedures, and litigation (Cooper et al. 1996; Firth-Cozens 1993).

Health care providers around the world are subject to pressures resulting from a sharp escalation of change, growing economic pressures, technological advances, increasing patient expectations, rationing of health care, and the requirement for more evidence-based and high-quality health care, improved performance, and productivity. It is well documented that health workers experience higher levels of stress and stress-related health problems than other occupational groups (Borill et al. 1996, 1998; Caplan 1994; Cooper and Mitchell 1990; Dawkins et al. 1985; Firth 1986; Firth-Cozens 1993; Harris 1989; Moore and Cooper 1996; Rees and Cooper 1992; Rodgers 1998; Williams et al. 1998). Among health worker groups, those thought to be most at risk for developing chronic stress syndromes are emergency service workers and mental health professionals (Clohessy and Ehlers 1999; Furnham 1997; Moore and Cooper 1996; Rees and Cooper 1992). Ambulance personnel, for example, receive more call-outs in a year than the police and fire services combined, and also have the highest rate of retirement on physical and mental health grounds compared to all other health care staff in the UK (James and Wright 1991; Rodgers 1998).

It is estimated that we spend on average at least 100,000 hours of our lives at work (Edelmann 1993), so it is important that we find it a satisfying and rewarding place to be. However, many health professionals are not experiencing their work as satisfying. In the UK health workers are leaving the National Health Service (NHS) in record numbers and, despite the uncertainty of the job market, there are chronic recruitment and retention difficulties. For example, it is estimated that as many as 14% of the doctors who qualified in the UK in 1988 are no longer practising medicine (Medical Workforce Standing Advisory Committee 1997) and, of doctors still practising, 22% say they regret their career choice (Clack 1999). One might argue that if someone is not happy in their work, then they should find another job. However, there are numerous reasons why the solution is not that simple. A health care professional may have invested many years training, may not be trained to do any other kind of work, or cannot afford to take a drop in salary. The employee may not have any alternative employment to go to, or be tied to a particular geographical area through personal and family commitments. There are thus numerous reasons why an employee cannot simply walk away from the job, and it is the long-term exposure to these unmitigated sources of stress which can lead to harmful effects on an employee’s physical and mental health. Since the NHS is one of the largest employers in Europe, it is of crucial importance that occupational stress among health workers is tackled as a matter of priority.

Traditionally, the wisdom of management theorists has been that employee casualties were an inevitable and acceptable sacrifice for organizations to make in order to remain productive and profitable, and that work organizations had no responsibility to cater for the ‘neurotic tendencies’ of employees (Rose 1982; Taylor 1947). However, more recently it has been recognized that addressing occupational stress in the workforce makes sense not only on humanitarian grounds but it also makes sound economic sense. The current state of thinking is that it is possible to achieve a balance between the ‘costs and benefits’ of work, whereby the needs of both the organization and the individual can be successfully met, allowing the individual to remain healthy and motivated in their work and at the same time allowing the organization to remain productive (Beehr and Bhagat 1985; Cooper and Payne 1988; Lowman 1997; Matteson and Ivancevich 1987; Quick and Quick 1984).

The main focus of this book is on presenting a range of detailed intervention strategies aimed at reducing occupational stress. However, before looking at these, it is important to conceptualize and define what is meant by stress.

DEFINING STRESS

Stress is a general term which refers to two distinct concepts, namely ‘stressors’ (environmental characteristics, or thoughts which cause an adverse reaction in the individual) and ‘strain’ (the individual’s adverse reaction to the stressor) (Beehr and O’Hara 1987; Knapp 1988). Over the last 50 years or so, a large number of definitions of stress have been proposed (e.g., Di Martino 1992; Fontana 1997; McGrath 1970; Monet and Lazarus 1977). These definitions have focused on certain situations as being stressful, on individuals’ responses to these situations or on both. Examples of stressful situations include excessive noise, heat, insufficient income, too much work, overcrowding, too little stimulation, death of a close family member, divorce or a jail sentence (Glass and Singer 1972; Grosser et al. 1964; Holmes and Rahe 1967). The response-based conceptualization is typified by Selye’s ‘general adaptation syndrome’ (Selye 1936, 1946, 1974, 1975, 1976, 1983). Selye described three stages in the body’s response to stressful situations, consisting of an initial alarm reaction, an adaptive middle stage and a final stage of exhaustion.

There is now a recognition among stress researchers that situation– response-based conceptualizations of stress are insufficient to explain the mediating factors within individuals which modify their susceptibility to environmental events and the stress consequently experienced. As a result of the ‘cognitive revolution’ in psychology, there is a growing consensus that stress is cognitively mediated and the product of an interaction between the individual and their environment (Lazarus 1993; Lazarus and Folkman 1984; Lazarus and Launier 1978). This approach has become known as the ‘transactional’ conceptualization of stress and it asserts that most situations or events are not in themselves intrinsically stressful but only become stressful when an individual appraises them as such (Beck 1984, 1987; Breslau and Davis 1986; Cox 1978, 1993; Di Martino 1992; Forsythe and Compass 1987; Lazarus 1975, 1976, 1977, 1982; Lazarus and Folkman 1984; Meichenbaum 1977; Ostell 1991; Singer 1986).

A COGNITIVELY MEDIATED MODEL OF STRESS

The model of stress presented in Figure 1.1 is adapted from Beck’s model of stress (Beck 1984; Beck et al. 1979, 1985; Pretzer et al. 1989). It proposes that the way in which an individual interprets and evaluates information from the environment determines the individual’s emotional and behavioural responses to it.

Figure 1.1 A cognitively mediated model of stress.

When an individual is under stress, information processing becomes disordered and manifests itself as distorted thinking, emotional distress and associated maladaptive patterns of behaviour. In this model, cognitions mediate directly between stressful life events and emotional distress.

Beck (1984) identified a number of steps in the model, which correspond to those presented in Figure 1.1.

Step 1: The first ‘snapshot’ of an event or situation

The stress reaction is triggered by specific events or situations. Beck (1984) used a camera analogy to describe an individual’s construction of a particular situation or event and likened it to taking a ‘snapshot’. In taking a photograph of a particular event or situation, the existing settings of the camera (lens, focus, speed and aperture settings) determine the eventual picture obtained. For example, there may be some blurring or loss of detail due to inadequate focusing, or some distortion or magnification of the picture if a wide-angle or telephoto lens has been used. In a similar way, the existing ‘cognitive settings’ of an individual will influence the way in which he or she perceives an event or situation. The underlying structures which determine an individual’s pre-existing cognitive settings are called ‘schemata’ (Beck 1972, 1995, 1996; Beck et al. 1990; Padesky 1994). Schemata are stable structures that select and synthesize incoming information as described in the camera analogy. They provide the meaning of an event for the individual and are the starting point for triggering a subsequent sequence of cognitive, emotional, physiological and behavioural events.

Schemata are formed through early life experiences. If the individual has had a healthy and stable early environment, then these schemata are likely to be equally healthy and adaptive. However, if the individual has experienced toxic early environmental life experiences, for example abuse or trauma, or not having their physical and/or core emotional needs reliably met, then these schemata are very likely to be unhealthy and maladaptive ones. In a non-threatened state (non-stressed), these schemata are dormant and inactive but they are reactivated by specific stressful events, which thematically resemble the adverse earlier experiences upon which the schemata are based. For example, if the individual experienced significant rejection in childhood, he or she will be particularly sensitive to situations or events that signal rejection. Thus, a situation signalling rejection to this individual will result in ‘hyper-activation’ of that particular schema. These specific sensitivities or vulnerabilities refer to an individual’s propensity to over-react to certain highly specific situations in an idiosyncratic way determined by the underlying schemata (Saul 1947).

In a non-threatened state (non-stressed), individuals may not perceive their maladaptive schemata to be plausible and can display relatively normal and adaptive information processing, emotions and behavioural responses. However, when the unhealthy schemata become hyper-activated in the way described above (when stressed), they become much more plausible, potent and dominant, and are difficult to switch off. In the example of the schema for rejection cited above, the individual begins to feel and behave as if they were in reality being rejected. Thus, schemata are considered to be at the core of the cognitive disturbance experienced in stress reactions (Beck 1967, 1972, 1976, 1996; Beck et al. 1990; Padesky 1994). However, it is their rigid, extreme, global nature, rather than the content of the schemata, that leads to psychopathology (Beck 1995). The initial snapshot of a situation corresponds to what Lazarus called ‘primary appraisal’ (Lazarus 1966, 1977; Lazarus and Folkman 1984; Lazarus and Launier 1978) and Freud (1914) called ‘primitive thinking’. It is the person’s initial judgement of the situation and is concerned essentially with decisions about the presence or absence of threat. The first snapshot taken thus provides information that either reinforces or modifies a pre-existing cognitive set.

Step 2: The activation of the emergency response

If the individual’s initial appraisal is that there is a threat to their vital interests and there is a clear and present danger, then the ‘emergency response’ is activated (Beck 1984). Triggering situations include those where there is a threat to self-preservation, survival, functioning, attachments or status, such as imminent physical attack, abuse, harm or punishment, but there can also be more subtle ‘social’ triggers such as criticism, rejection, abandonment, deprivation, loss of social status and social exclusion (Beck 1996). One might ask why social situations should trigger the emergency response. Whilst this may be difficult to appreciate in our modern Western society and culture, it has been argued that from an evolutionary perspective, ‘sociability’ and being an accepted part of a social group has historically had crucial evolutionary survival value (Gilbert 1989). In more primitive societies, it not only provided protection from physical attack and support in the fulfilment of one’s basic needs for food, warmth and shelter but also allowed for the formation of relationships that might ultimately lead to sexual reproduction.

Beck (1984) proposed that while the pre-existing cognitive settings are signalling a threat to one’s vital self-interests, the individual is also taking a second snapshot, which is assessing their resources to cope with it. The individual will not experience stress unless he or she decides that resources are inadequate to cope with the threat. This evaluation of coping resources will be influenced by the individual’s experience of previous similar situations, beliefs about him/herself and the environment, and assessment of personal or environmental resources. If the risk is appraised as being high in relation to the individual’s coping resources, the emergency response is activated. This secondary appraisal plays a central role in the subsequent development of the stress reaction (Lazarus and Folkman 1984; Lazarus and Launier 1978). It is thought that both the primary and secondary appraisals are unconscious, automatic, involuntary and non-reflective processes, which take place at high speed.

Step 3: Activation of cognitive–affective– motivational systems

Once the emergency response has been elicited, normal cognitive information processing is replaced by more primitive information processing, known in psychoanalysis as ‘primary process thinking’ (Beck et al. 1979). In this primitive thinking mode, the individual makes more rigid, absolute, extreme, crude, simplistic, global, dichotomous, one-sided judgements. These can produce highly idiosyncratic cognitive distortions, which can ultimately become so potent that they totally dominate the individual’s feelings and behaviours. Crucial cognitive functions such as objectivity and reality testing are seriously disrupted (Caplan 1981). There is also a tendency to ‘frame’ others who are perceived as a threat in terms of a few simple and extreme negative characteristics (polarized thinking). This, together with a greater tendency towards egocentricity (i.e., others do not come into the equation), can result in increased interpersonal conflicts, as others around the stressed individual respond negatively to their ‘selfish’ and ‘hostile’ patterns of thinking.

Secondly, behavioural inclinations are activated. These are not act...

Table des matières

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• LIST OF FIGURES AND TABLES
• ABOUT THE AUTHOR
• NOTES ON CONTRIBUTORS
• PREFACE
• ACKNOWLEDGEMENTS
• PART 1: INTRODUCTION
• PART II: STANDARD INTERVENTIONS FOR OCCUPATIONAL STRESS
• PART III: A SCHEMA-FOCUSED APPROACH TO OCCUPATIONAL STRESS
• REFERENCES