Published on February 16, 2014
John Keen Cognitive Behavioural Therapist Clinical Director Cognitive Behavioural Therapy Centre www.thecbtcentre.org
What is stress? What is stress in the workplace? The cost of stress • i.e. Humanitarian • Economic • Models of stress • Why do we get stressed? • What can we do for ourselves? • Conclusions Discussions • Any questions • Next steps
Statement • ' The cost 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' • Agree or disagree
If agree Why does management do so little about it?
Background • Occupational stress is costing the UK economy billions of pounds each year through sickness absences and ill health retirement. • Litigation and poor poor work performance, this is on the increase • A survey carried out in the UK in the year 2000 toward that half a million employees were surveyed from work - related stress. A rise of 30% from 1990 • Given that Staff Account for high levels of the cost (NHS=80%) • It is clear that reducing occupational stress not only makes sense on humanitarian grounds but also makes sound economic sense.
Conceptualization of stress • pressure mounts on workers to become ever more productive. • • it is estimated that up to 40% at all sickness absence from work is due to stress. the cost alone to employers and health insurance is billion of pounds each year. Occupational stress is an unfortunate consequence of this. The Cost is not Just Money • it also includes 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 Time + financial costs also related to redevelopment returning replacement grievance procedures and litigation
Conceptualization of stress - It is estimated that we spend on average at least 100,000 hours of our lives at work - One might argue that if someone is not happy at their work, then they should find another job. - However these are numerous reasons why the solution is not that simple. - Traditionally, the wisdom of Management theorists has been that employee casualties were as inevitable and acceptable sacrifice "we can't cater for neurotic tendencies” - The current scale of thinking is that it is possible to achieve a balance between the costs and benefits of work.
Defining Stress Stress in general terms refers to two different concepts. Namely "stressors" (environmental characteristics or thoughts which cause an adverse reaction in the individual) "Strain" ( the individuals adverse reaction to the the stressor) Example 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
Defining Stress Selye described 3 stages in the body's response to stressful situations consisting of: • • • an INITIAL ALARM REACTION an ADAPTIVE MIDDLE STAGE then A FINAL STAGE OF EXHAUSTION.
Models of stress Becks Model Proposes that the way in which an individual interprets and evaluates information from the environment determines the individuals emotional and behavioural responses to it. (examples) When an individual is under stress, information processing becomes disordered and manifest itself as distorted thinking, emotional distress and associated maladive patterns of behaviour. (example)
The Activation of the Emergency Response If the individuals initial approval is that there is a threat to their vital interests and there is clear and present danger, then the "emergency response" is activated. Triggering Situation include those where there is a threat to Self preservation, • • • • • Survival Status Inherent Physical Attack Abuse Harm or punishment
The Activation of the Emergency Response These can also be more subtle "social" triggers such as • • • • • Criticism Rejection Abandonment Deprivation Loss of social status and social exclusion Why Should We Feel Threatened by Social Situations Evolution
The Three Response Systems The three-systems analysis of emotion PHYSIOLOGICAL BEHAVIOURAL COGNITIVE The three response systems - autonomic, behavioural and cognitive - occur in any one individual and situation to varying degrees depending on the person and the situation, known as the degree of ‘synchrony’ of the emotional response.
The Fight-Flight Response • • • • • • • • Brain sends message Adrenaline is released Muscles tense up Heart beats faster Breathing increases Nausea & sweating Senses sharpen Mouth dries
How Arousal Affects our Bodies Eyes pupils dilate vision sharpens Mouth & Throat mouth dries difficulty swallowing Heart beats faster to get more blood & oxygen around body results in palpitations & blood pressure increases Bladder & Bowels Brain triggers fightflight response Lungs breathing quickens to increase oxygen in the body Sweat Glands body overheats sweat is produced to cool the body Stomach increase in acid & uncomfortable stomach urge to go to toilet Knees adrenaline immobilises knees & knees feel weak Fingers Hands & Feet tingle due to reduced blood supply
The Three Response Systems BEHAVIOURAL PHYSIOLOGICAL • Heart rate increases • Palpitations • Blood pressure increases • Tingling in limbs • Over breathing • Tightness in chest • Sweating & hot flushes • Cold sweats • Aches & pains • Shaking limbs • Butterflies nausea COGNITIVE
The Three Response Systems BEHAVIOURAL PHYSIOLOGICAL AUTONOMIC • Escape from the situation • Avoid the situation • Develop behaviours designed to protect self from harm COGNITIVE
The Three Response Systems PHYSIOLOGICAL AUTONOMIC BEHAVIOURAL •“This is awful” •“I`m going to collapse” •“I’m going to faint” •“I’m going to look stupid” COGNITIVE
The Three Response Systems Physical Sensations Sweating, shaking, palpitations Behaviour Avoid the situation Escape from the situation Thoughts “This is awful” “I’m going to faint” “I’m going to look stupid”
The Development of Stress Symptoms Prolonged exposure to situations or events perceived as threatening to ones vital self interests and/or survival. Without any successful resolutions, results in the emergency response becoming chronically activated, leading to the development of stress symptoms. This manifests itself as three main stress symptoms. • The Hostility Syndrome In this syndrome, individuals are hypersensitive to events that signal restraint, trespass or assault. (the behavioural coping strategy is by the desire to counter attack and fight perceived challenges. The emotional response consists of feeling irritation & extreme full blown rage) • The Fear Syndrome This is where individuals are hypersensitive to events that signal threat or danger. (The behavioural coping style is the desire to flee and escape the perceived dangers and threats)
The Development of Stress Symptoms The Depression Syndrome In this Syndrome the negative thoughts are activated and individuals develop a negative view of these SELF, the WORLD and the FUTURE. (The Behavioural coping style is characterised by the desire to give up and surrender. The negative constructions of events and feelings range from mild sadness to depression and, in the extreme, abject despair and the risk of suicide)
Why do we get stressed? Is it work or is it ourselves to blame? From what we have learned IE our thinking proccess and behavioural coping strategies. These all have a part in occupational stress. This is not to imply that the work environment is never to blame, or that the individual is always responsible for their own stress. Clearly this is an interaction between the individual and the work environment.
Personal factors Genetic factors It is acknowledged that, genetically, some individuals are physically stronger and intellectually more able to meet the demands when a job makes upon them. It has been reported that there are sex differences in the way males and females cope with stress. However, it is of course debatable whether this sex difference should be considered as a genetic factor or a learned predisposition.
Personal factors Learned factors It has been suggested that younger individuals are more vulnerable to stress than other individuals. It is argued that an individual who has more experience is less likely to suffer from stress due to "mastery of the past" which can inoculate one against stress.
Personal factors Personality factors Numerous studies have found that "non hardy" individuals i.e. those who have "traits" of being anxious, are prone to to stress. (ie type A personalities) Compared to the natural more hardy individuals. Example Type A personalities show greater physiological reactivity to stressful conditions. There is also some evidence at more disease i.e. heart disease, peptic ulcers, allergies and respiratory infections.
Environmental Factors Several work stressors have been found These include: - financial remuneration - poor physical work environment - outdated technology - high workload - excessive responsibility - low social position - lack of autonomy and control - variety in job - external job demands/goals - role conflict and lack of clarity - lack of support - poor career prospects All the above have been identified as sources of stress in the work environment.
"Content" and "context" of work Research has been done on the above two groups of work characteristics. Content This recognises the need for safe, supportive, comfortable, ergonomically sound work environment in which to work and the requirement for the resources and equipment to do the job effectively. This includes the need to accommodate social and welfare needs, sufficient rest periods, sociable working hours and conditions A variety of tasks and manageable volume of work conducted at a comfortable pace. Content at work - is an important factor in determining levels of occupational stress.
"Content" and "context" of work Context Individuals need to have a clear understanding of the goals , norms and ideology of the organisation and clarity regarding their own role and responsibilities within it. They require security of employment fair financial remuneration clear identified management structure and lines of accountability within it. Clear channels of communication Regular feedback about performance Career and promotion prospects Appropriate training to do the job. (The employee needs to feel that they have some discretion and control over the job content, that they are part of the decision making process and that they can influence decisions made within the organisation. )
"Content" and "context" of work An ideal world. However working in an organisational environment which lacks any of the "Content" and "Context" requirements can result in occupational stress.
"Content" and "context" of work Unfortunately all organisations have their fair share of psychologically immature and personality disordered individuals, who can wreak havoc on an organisation. The problem can be magnified if such individuals are on a position of authority, since it is estimated that as much as 90% of a manager's time is spent in interpersonal context. Divisive and disruptive behaviours such as following: Favouritism forming cliques showing prejudice unwanted criticism pulling rank taking advantage of power ignoring others not allowing others to take the lead withholding information promoting those who are least likely to threaten a manager refusal to negotiate imposing decisions without discussion criticizing subordinates publicly These are extensive use of put-downs, personal and unprovoked attacks and blaming and patronizing others are just some examples of interpersonal behaviours which cause considerable distress for others.
The Home-Work Interface Behaviour at work does not take place in a a vacuum. It is influenced by extrinsic factors and this is known as the home-work interface. A good marriage and social support from friends families and relatives can act as a buffer against stress at work. Dual careers can put considerable strain on a marriage. For example, males are expected to move readily for job transfers and promotion if they want to progress in their careers and it is traditionally expected that their family and spouse follows them. Associated with dual careers is the fact when the females occupational prestige or income equals or exceeds that of their male spouse, this can lead to marital tensions. Research has suggest that women in such positions commonly try not to be "too successful" and may even reject promotions in order to prevent such con conflicts from arising. Also, despite the increase in women going out to work, responsibility for maintaining the household and child care still falls mainly on women.
The Consequences of Occupational Stress They are briefly summarized Physical Individuals may experience symptoms such as: - muscle pains - tremors - palpitations - diarrhoea - sweating - respiratory distress - headaches - backache - poor sleep - loss of libido - increased heart rate - raised blood pressure - dry mouth and throat - indigestion Psychological Individuals may experience -feelings of unhappiness - worrying more than usual - increased irritability - reduced job satisfaction - reduced motivation and commitment to the organisation.
The Consequences of Occupational Stress Behavioural These indicators include: Increased smoking Increased alcohol consumption less attention paid to eating a healthy diet increased use of tranquillisers Social These indicators include - withdrawal - strain on relationships - increased marital and family conflicts With more chronic (severe and prolonged) levels of occupational stress More serious physical and mental health problems can occur. Research has shown in these cases with prolonged stress, strain on physiological systems of the body can occur ie •raised blood pressure •damage to coronary arteries •gastric complaints •Ulcers •coronary heart disease Mental health - severe anxiety and depression.
Conclusions It is a fact that the two most common mental health problems seen in NHS occupational health services are anxiety and depression. I don't think for a moment that your occupational health services are different. NHS Research Occupational Health Showed anxiety in various forms was 25% of all referrals Depression was 23% of total referrals Other studies have shown higher figures Anxiety at 52% Depression 24% Other less commonly referred problems include - burnout 15% posttraumatic stress reactions to work related trauma 8% anger management problems 5% Although we don't talk about stress/anxiety/depression it is with us more commonly than you think.
WHAT CAN WE DO FOR OURSELVES There is a wealth of literature and beneficial effects of individual stress management interventions. I would like to go through some of these with you. Developing A Healthy Lifestyle Health promotions programmes run by workplace organization aim to educate employees about the importance of - regular exercise - healthy diet - moderation of alcohol - medication usage - stopping smoking - getting the right amount of sleep Research showed that employees involved in such programmes showed significant reduction in - weight - body fat - systolic and diastolic blood pressure - absenteeism - accidents
Even if your employers don't offer these facility Local Councils, GP Practices etc NHS do offer helpMany organisations however do encourage their employees to - Keep fit by offering opportunity to join a gym at reduced Corporate Rates - Access to a dietary advice and support from a dietician or occupational health team. - Organisations often provide a staff canteen. This can provide a range of healthy options. - Encourage employees to drink 2 litres of water a day - Education re consumption of alcohol. Occupational Health Teams Human Resources can periodically do health promotions 21 units for men 14 units for women - Smoking NHS Health promotion Team are often happy to attend by workforce campaigns to do promotions. - Sleep issues Again often can be an indicator of stress issues Your occupational health team will give advice re Sleep Hygiene.
Developing Effective Time Management Skills • • • Effective time management has become increasingly more important in seeking to achieve organisation objectives of efficiency and effectiveness. There is considerable evidence to suggest that poor time management is a significant problem in the workplace. Research shows: An estimated 20% of office workers time is wasted or cost in non-essential or wasted tasks. That 70% of manager's time is spent in meetings (it is questionable how much time of this is wasted) 13% of mail received by managers was specific and immediate relevance to them The benefits of managing time effectively include greater: - efficiency and effectiveness at work - higher productivity - enhanced job satisfaction - reduced stress - increased leisure time - more room for forward planning
Developing Effective Time Management Skills Time management involves creating more time and using time more effectively. It involves prioritizing essential above non-essential tasks. (often we take on too much try to do everything feel overwhelmed) Planning ahead Setting time limits Not allowing oneself to get side tracked Giving oneself enough "prime time" to plan and organize the working week.
HAND OUT • Some examples of behavioural changes that can be made in order to manage time more efficiently. Plan ahead • It is estimated that 1% of wrong time spent planning is required to produce on average saving at one hour a day Making a "to do list" into a hierarchy can also be helpful in terms of identifying priority and nonpriority tasks. Once identified the top priority items can be treated first and allows others left till later. • Prepare for meetings. Know what you want to get out of a meeting and what you input will be in advance of it. it is also important to agree the timing of meetings at the beginning of the meeting and stuck to the agreed time limits. Stick to the Agenda and ensure that you communicate clearly. if necessary, rehearse what you have to say in the meeting. Keep them as short as possible and once you have achieved what you want in the meeting excuse yourself from it. Unnecessary meetings should be avoided.
HAND OUT • • • • • • • Where appropriate use the telephone, email, letters or fax instead of time consuming meetings. Letters should be kept as brief and to the point as possible and standardized letters should be used where appropriate. avoid idle chatter. While social chit-chat may be enjoyable, it can be a big time waster. Face to face and telephone conversations should be polite but whenever possible kept brief. reducing a coffee break down from 15 mins to ten mins and limiting social chatter in the corridor can free up a considerable block of time throughout the week. Making use of a secretary to make calls or the use of answer phone can be helpful in protecting oneself from excessive demands in the workplace. delegate certain tasks where appropriate. group tasks into chunks, such as grouping all your telephone calls and doing them all in one go. Blocking out time to do this can be necessary to put up a "do not disturb" sign when doing this. practice publicly saying "no" to requests in order not to become over-loaded with work. It is important to avoid procrastination and delaying unpleasant tasks or decisions by doing them as soon as possible when they arrive. If a by task seems overwhelming then it can be broken down into several smaller more manageable chunks and each one tackle in return. choose the best time to tackle difficult tasks certain times in the day when we are at our best. In summary, effective time management can result in greater productivity and reduce stress levels.
ASSERTIVENESS TRAINING There are numerous studies reporting the beneficial effects of assertiveness. Assertiveness is a key skill required by health workers, in order to interact effectively with patients, peers and colleagues. It Involves being able to stand up for your own rights in such a way that you do not violate the rights of another person. It is about expressing one's needs, wants, opinions, feelings and beliefs in direct, honest and appropriate ways and creating a win-win situation for all involved. There are various reasons why a person may be unassertive. These may include a lack of confidence; fear of conflict, disapproval, others becoming angry, losing one's job or failure; or the desire to be looked after and protected by others. Unassertive people often feel guilty if they refuse a request, do not realize that they have rights too and have irrational negative thoughts about themselves. they may also confuse assertiveness with aggression and equate nonassertiveness with politeness. Unassertiveness can also have effects on others, who initially may feel sorry for the unassertive individual but ultimately it can lead to a lack of respect for them, because others do not know what the person stands for. They may begin to doubt that person's integrity, believing that they say one thing and go away and do another. They may become irritated that the unassertive individual does not say what they really want. in Addition, it can also have effects on the workplace organization when conflicts are not handled satisfactorily, difficult decisions are made and staff lose respect for a manager who is unassertive. Assertiveness training focuses on four main areas.
Education • This involves learning to recognize the differences between assertive. unassertive and aggressive behaviours in both their verbal and non-verbal expressions. • For example, Aggressive verbal statements include excessive use of "I" statements, boastfulness, sarcastic comments, putdowns, threats and blame, whereas unassertive verbal statements include long and rambling statements, permission seeking, self putdowns and excessive apologies. • Assertive verbal communication involves giving clear statements which are concise and to the point, constructive advice and criticism, and suggestions and not blaming others unfairly. Non verbal communication involves facial expression, eye contact, bodily posture, personal space, tone and volume of voice and pattern ( as opposed to content) of speech. Aggressive non-verbal; communication involves raised eyebrows, firmly set jaw, scowling, starring eyes, finger pointing, fist thumping, upright posture, invading of personal space, hard and sharp tone of voice, abrupt speech pattern and raised voice volume (shouting) • Unassertive behaviour includes avoiding eye contact, nervous and hesitant movements, hunched shoulders, "ghost" smiles, soft and wobbly monotone voice filled with hesitation and frequent throat clearing. Assertiveness involves good but not staring eye contact, open gestures nd movements, relaxed posture, steady and non-threatening facial expression and sincere, firm and steady voice. •
Knowing one's rights Most employers recognize that employees have a number of rights and these usually from part of their contracts of employment, such as annual leave entitlement, terms of employment, sickness pay, study leave entitlement and maternity/paternity leave entitlement. Most of these are statutory rights covered by government legislation. At work these rights may extend to non statutory rights such as the right to a job appraisal, time off in lieu, in-service training and continuing professional development without loss of pay. Also, this extends to having a right to know what is expected, to be consulted about decisions made affecting you, to refuse certain requests, make mistakes occasionally without fear of being sacked and so on. Employees also have responsibilities, such as turning up to work on time, adhering to a certain dress code, using time productively, putting mistakes right, learning from mistakes and trying not repeat them and abiding by the terms and conditions of employment. However, they also have rights as human beings, which are deemed necessary to live a decent life. These include, for example, the right to be treated with respect, to be treated as an equal, not to be bullied or harassed, to be listened to, to make mistakes from time to time, to change one's mind and to refuse an unreasonable request. Assertiveness training focuses on the rights of the individual as a human being since it is in these areas that unassertive individuals typically experience the most problems.
Developing assertive attitudes This focuses on identifying aggressive and unassertive beliefs and attitudes and changing them to assertive ones. Examples of aggressive attitudes include, "Aggression gets results", "Attack is the best form of defence", and "I must give as good as I get" Examples of unassertive attitudes include, "My opinions don't count", "I m not s important as others", and " It is safer not to challenge people". Assertive attitudes include, for example, " I am in control", "I am responsible for what happens to me", and "I am as good as others“ Developing assertive behaviours The individual may define a hierarchy of behaviours which they wish to change and start off with making small changes as, for example, making a request, refusing request, disagreeing with someone, giving an opinion, giving praise, receiving praise and so on. They may also practice nonverbal behaviours such as good eye contact, open gestures and movements, relaxed posture and steady and non-threatening facial expression, and verbally communicating assertiveness through developing a firm and steady voice, which is warm and sincere. Role-play and rehearsal in imagination techniques can be particularly helpful when practising assertive behaviours. The individual gradually moves up through a hierarchy of situations, confronting progressively more difficult situations. However, they do not move higher up the hierarchy until they feel that they are successful with the current task.
SOCIAL SKILLS TRAINING It is assumed that most employees already possess the necessary basic social skills is to do the job, otherwise they would not have got through the selection process. However, there are higher order social skills, which workers can learn to use in their every day work, to manage their interactions with others better and get the best out of them. These include making a good first impression, holding one's own in a conversation, making appropriate self-disclosures and giving praise and encouragement. It involves the management of professional relationships, including making social judgements, attributing motives, active listening, breaking bad news and handling angry confrontations. It is also about demonstrating fairness, consistency, loyalty, warmth, honesty, openness and empathy. Fontana (1994) suggested that one needs to ask oneself some questions to establish how socially skilled one is. These include: "Am I projecting myself in the best way?" "Do others see me in the same way I see myself?" "Do I know those I work with very well?" "Am I consistent across situations and people?" "Am I good at judging others and their motives?" "Am I good at communicating with others?" "Am I good at picking up subtle social signals?' 'Am I a good listener?'
SOCIAL SKILLS TRAINING If the answer to any of these is 'no', then Fontana suggests that there is work to be done. Social skills can be learned through training workshops of a practical nature and the use of role-play and or audio or video feedback can be particularly helpful in learning social skills. these may include the following: • Effective verbal communication skills such as the ability to not monopolize conversations, to show interest, to listen, to recognize the signals which tell us we are boring people, to recognize our annoying mannerisms and to talk at the right level for the listener. • The ability to pick up on non-verbal cues, such as eye-contact, body posture, movement and facial expressions such as nods, frowns, laughter and so on. • Active listening skills and attempting behaviours such as communicating warmth and empathy, talking in a soft voice, adopting a non-judgemental attitude, making good eye contact, using friendly facial expressions and adopting an interested posture by leaning forward with arms uncrossed. This also includes the use of listening skills such as summarizing, paraphrasing and reflecting back, which all demonstrate attending and listening. • Awareness of appropriate physical contact. The rules of contact vary in different socio-cultural contexts and with the closeness of the relationship. The closeness of appropriate contact thus varies and the employee needs to be aware of these rules. For example, an arm on the shoulder of a distressed patient or colleague may be appropriate but an arm on the shoulder of a non-distressed patient or colleague may not be so in context of a meeting.
POSITIVE THINKING The centrality of negative patterns of thinking in mental health problems and the beneficial effects of positive thinking is well reported. • • • • • • This strategy essentially involves teaching the individual identity, label and challenge their negative thinking patterns, using the cognitive techniques outlined in chapter 3. Some common examples thinking include the following: Selective attention - the tendency to focus one's thinking on and attend only to the negative parts of one's life, while ignoring all the positive things that happen. Jumping to conclusions - assuming that the worst is going to happen without evidence and before it happens. this involves making negative predictions about the future, such as 'I know I'll make a mess out of things', 'I know this treatment won't work' and so on. Also, instead of finding out what people are really thinking, the individual 'mind reads' and this is rarely successful. Black and white thinking - thinking in 'all or nothing' terms. The world is seen in terms of dichotomies, such as people are either all good or all bad, 100% successful or failure, strong or weak and so on. Shades of grey do not seem to exist for black and white thinkers. Magnification - the tendency to exaggerate the importance of negative events and blow them out of proportion, such as, 'I got question nine wrong' without reference to the fact that all the other answers were right, or 'Last Tuesday evening was awful' without acknowledging that the other six days of last week were enjoyable. Minimization - playing down the significance of positive events and achievements, often attributing them to luck, chance or the skills of others but never on one's skills. Yet at the same time all failures are attributed to one's own incompetence (as in magnification) Overgeneralization - a single negative event is seen as part of a never ending pattern of defeat. It is often accompanied by the terms 'never' or 'always': for example, 'I never have any success'. 'I always upset people'
POSITIVE THINKING • Negative predictions -predicting that things will always have the worst outcome. Catastrophizing is an extreme form of this. • Should statements - trying to motivate oneself with "shoulds" and "oughts" but invariably ending up feeling guilty as a result of not meeting these expectations or resentful towards others who do not meet these expectations • Labelling - applying a critical label to oneself instead of accurately describing the situation. instead of saying, 'I didn't do that job as well as I might have done' one say 'I'm a failure‘ • Personalization - the tendency to see oneself as the cause of some negative events, for which one is not necessarily responsible. Neutral events are interpreted as having negative significance for the individual. For example, a friend cancels an evening out and you think it's because they don't like you, or your children behave badly and you think it's because they don't like you, or your children behave badly and you think it must be your fault. similarly, someone might snap at you and you blame yourself, thinking, 'I must have deserved it' This is not of course an exhaustive list and there are other examples.
PROBLEM SOLVING Common sense tells us that problem solving skills are important for our daily living. To a degree we learn these skills through experience but the acquisition of these skills through experience but the acquisition of these skills is very much left to the chance, and a more systematic approach to problem solving can be very helpful in terms of managing stress. One such approach is that of Egan (1990). For Egan, the starting point is to get the individual to identify and describe their 'present scenario' (point A), which is the present unacceptable state of affairs or 'current mess' that they find themselves in. They are then asked to identify their preferred scenario (point B) at some time point in the future and to describe what this would be like ideally. Where would the individual ideally like to be? Who with? What doing? What would they want to be different or change? What would make them feel happier about their life? It can be helpful in getting the individual started to ask them, 'If you could wake up tomorrow and everything was sorted out, what would it be like?' The client is then asked to consider how they might get from point A to point B. They are asked to generate a whole range of options or possibilities. Some people tend to want to engage in the first option they come up with. However, they should be encouraged to explore a range of different ways in which their goal can be accomplished. One very useful technique is called 'brainstorming'. In brainstorming the individual is asked to think of as many ways of achieving the goal as possible and write these down. They are encouraged to list everything, however silly or unrealistic it might seem to them at the time. Once a range of options has been identified, each can be reviewed in turn. The best 'fit' ( the best single option or combination) is then selected. 'Best' means the option which best fits the client's needs, preferences, values and resources and is the most realistic option in that it is least likely to be blocked by their environment. The individual is then helped to formulate a plan to achieve each goal, identifying shorter-term objectives on the way towards longer term goals. The aim is thus to assist a transition from the current scenario to the preferred scenario. (Egan 1990)
RELAXATION TRAINING Informal techniques Easton(1990) found in a survey that informal methods of relaxation were, in order of popularity: • • • • • reading watching television playing sports taking a bath hobbies It is not advisable to be too prescriptive about informal methods of relaxation, since everyone has their own unique preferences and ways of achieving them. While one individual might enjoy having a hot bath and relaxing in front of the fire with a hot cup of cocoa, another individual may indulge in a vigorous game of squash to relieve their tension.
RELAXATION TRAINING Activities with more formal relaxation properties Activities such as yoga, massage therapy and various forms of meditation are known to have relaxing properties and should be encouraged in the individual suffering from stress. Formal relaxation training techniques Progressive muscular relaxation exercises involve teaching the individual to register the difference between tension and relaxation in various groups of muscles, so that they can learn to calm the body when they are feeling anxious. there are two reasons for relaxing in this way. first, when a person is suffering from anxiety, tension becomes such a habit that they no longer notice it. These exercises thus make them aware of the differences between tension and relaxation. Second, by tensing the muscle we also fatigue it and so make it easier to relax. Correct breathing involves slow, deep breathing in through the nose and out through the mouth using the whole of the lungs. When people are anxious or panicky they tend to over breathe using the upper part of the chest and bring on further unpleasant symptoms as a result of hyperventilation. The individual can learn to breathe in a more relaxed way and this can assist in the relaxation process. Breathing correctly is very important in managing anxiety. Conclusions There is a wide range of cognitive and behavioural tools and techniques, which the individual can make use in order to help them cope more effectively with work related stress. this toolkit can help provide a buffer against the stresses inherent in the work situation.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Checklist Eat a healthy diet Watch your weight Avoid long term use of medication Get regular exercise Get sufficient rest and sleep Keep alcohol consumption to a moderate level and do not use it as a coping strategy Identify and make use of your own informal relaxation techniques If necessary make use of more formal relaxation and meditation techniques. Know your own limits and do not overstretch yourself Learn to recognize the signs of stress in yourself and your work colleagues Where appropriate learn to delegate to others Don't be a slave to approval. You can't please everybody all the time. Take rests in a busy scheduelle. The busier you are, the more important it is to take breaks. As a general rule, try always to take lunch breaks Try to take a couple of coffee breaks throughout a shift Try to be tidy and organized in your work Plan ahead and be prepared Manage your time effectively Set aside prime time for thinking, planning and organizing Learn to pace yourself in your work and work at a pace which is comfortable for you. Learn to prioritize tasks Give yourself enough time to complete tasks Set realistic goals and work towards them Develop your assertiveness skills
Checklist 25. Learn to say 'no' more often 26. Identify the areas of weakness in your social and communication skills and work on improving these 27. Experiment with changing working habits and schedules and adopt those which feel more comfortable to you 28. Develop your assertiveness skills 29. As far as possible, separate the home and work environments 30. Learn to express your thoughts and feelings more skillfully to others 31. Develop your problem solving skills 32. Develop a more rational approach to life. 33. Be kind and nurturing to yourself and reward your success 34. Try to learn from your mistakes rather than punishing yourself for them 35. keep work in its rightful place 36. Establish what your priorities are in life and stop wasting time on other things which are not important to achieving these. 37. Seek a fair mix and distribution of workload 38. If possible, vary your work routine to avoid boredom 39. Try not to be afraid of change. Seek change and variety in a positive way 40. Develop a number of roles in your personal life outside work 41. Be realistic in your goals and don't promise what you can't deliver 42. Be positive in your thinking. 43. Do not base your whole identity on the job that you do 44. Accept that is ok to be average in some times 45. Don't procrastinate. Try to deal with difficult situations as and when they arise. 46. Confront your fears rather than avoid them and be prepared to come out of your comfort zone when doing so. 47. Learn to give, ask for and receive support more when is required.
What to do when Managing Stressed People The HSE has a Line Managers Resource A Practical Guide to Managing and Supporting People with Mental Health problems in the workplace. The government is now finally taking Sickness ?? Mental health Issues Seriously (Layard Report). Nearly 3 in 10 employees have a mental Health problem of some sort in any one year. 12.8 million working days were lost to stress, depression and anxiety 2004/5 costing billion each year. Many people forced to give up there jobs WASTE Many make good recovery - in the past / Ignored Other it is not their health that stands in their way. It is: - fear - ignorance - discrimination When they were telling employers about their diagnosis of their fear, ignorance, discrimination is unintentional.
A business perspective: Dr. Paul Litchfield, BT Businesses that don't take mental health seriously will not be successful in the 21st century. the global economy is changing fast and the capabilities that companies require now centre more on innovation, communication and emotional intelligence than just the more straightforward requirements of strength, dexterity and intellect that characterised previous eras. The world Health organisation estimates that by 2020 depression will become the second most important cause of disability in the world. Whatever the causes of increased mental illness, the reality is that it has become so common that people at work will inevitably have to deal with it in themselves, in their superiors or in those who report to them. Line managers and colleagues in the front line can make the biggest difference in the field of mental health at work. Reacting appropriately to signs of distress, maintaining contact with people who may be plumbing the depths of despair and constructing practical return to work plans for those recovering from mental illness are the simple things that can prove job saving and, sometimes, even life saving.
Talking at an early stage The earlier you notice that an employee is experiencing mental health difficulties the better for all concerned. Your early actions can help prevent the employee becoming more unwell. As a line manager, you can and should play a key role in identifying and addressing the barriers to normal working life the employee might experience rather than trying to understand his or her diagnosis. The longer you leave a situation like this the harder it is to solve the problem and indeed the employee might become more unwell. If an employee is already off sick it is more likely lack of contact or involvement from you might mean they feel unable to return. Your involvement and reassurance at an early stage will minimise risks of people not returning to work and any associated problems being difficult to solve.
Identifying early signs of distress. Some of the key things to look out for are changes in a person's usual behaviour, poor performance, tiredness and increased sickness absence. You might notice or colleagues might comment on an increased use of alcohol, drugs or smoking. A normally punctual employee might start turning up late or experience problems with colleagues. Other signs, particularly if someone is depressed might be tearfulness, headaches, loss of humour and changes in emotional mood. As a manager you should be aware of the wider organisation's impact on employees. It might be the case that certain tasks, work environments, times of the day or particular teams are more likely to be associated with people experiencing difficulties.
Using ordinary management tools to identify problems and needs Regular work planning sessions, appraisals or informal chats about progress are all ordinary management processes which provide neutral and non-stigmatising opportunities to find out about any problems an employee may be having. You might find it helpful use open questions that allow the employee maximum opportunity to express concerns in his or her own way. For example: "How are you doing at the moment?" "Is there anything we can do to help?" If you have specific grounds for concern - such as impaired performance, it is important to talk about these at an early stage. Ask questions in an in an open, exploratory and non judgemental way. For example, "I've noticed that you've sometimes been arriving late recently and wondered if there was a problem?" When talking to an employee three points to remember are: don't assume stress affects everyone equally • • make adjustments if a person is stressed, and 'chats' should be positive and supportive - exploring the issues and how you can help
Uderstanding patterns of absence If the employee is having frequent short bursts of sickness absence with a variety of reasons such as stress, back pain or there is no reason given, there may be underlying, if transitory mental health problem that should be discussed. If you are going to look systematically at patterns of absence, staff need to be able to trust you. They need to be reassured that your motive is to improve healthy working, not to castigate. It is good practice to have a 'return to work' interview when someone returns after absence. For brief absence this can be just a quick chat. It is always a useful opportunity to check how they are. It is important that these interviews happen for all absences - not just stress/mental health related absences.
Stress goes with the job - we're all stressed! It's helpful to make a distinction between 'pressure', 'stress' and 'mental health problems'. Everybody may feel under pressure but not everybody suffers the adverse reaction of stress or a mental health problem. Also, everybody reacts differently - one person's spur to action is another nightmare and a cause of paralysis at work.
Engaging with someone who is reluctant to talk First, make it clear that the discussion will be absolutely confidential. Then you should consider - from the employee's point of view why he or she might be reluctant to talk. Is it really safe for them to be open with you? Will any disclosures be treated sympathetically and positively? If this employee has seen others with similar problems being discriminated against then from their point of view they are wise to be cautious. You need to be realistic. You may not be able to change the culture of the organisation overnight but you may be able to take some first steps. In the short term you can meet the person in a private confidential setting. You could even meet outside the office in a cafe for example. You should reassure them your door is open to talk later if it is too difficult for them now. Before the meeting ask if the person wants to bring an advocate, friend or family member to support them in a meeting. Also consider some people might find it easier to talk to someone of their own choosing, e.g. someone of the same age, gender or ethnicity - or someone who is not their line manager. You should be clear about confidentiality and who will be told what. You cannot offer 100% confidentiality but can clearly explain the limits of your confidentiality (such as personal information is confidential but issues that may have a health and safety risk will need to be discussed further). Agree with the employee how problems will be monitored. If adjustments are being made, ask the person how they wish this to be communicated to other staff. You need to ensure that any hurtful gossip or bullying is dealt promptly and effectively. it is your responsibility under the disability, Discrimination Act to ensure that staff are not being bullied or harassed on account of a disability.
Issues to raise with an employee who is distressed • Ask open questions about what is happening, how they are feeling, what the impact of the stress or mental health problem is and what solutions they think there might be. • How long have they felt like this? • Are there any problems outside work that they might like to talk about and/or it would be helpful for you to know about? (You should not put pressure on the person to reveal external problems) • are they aware of possible sources of support such as: relationship, bereavement counselling, drugs/alcohol services/advice, legal or financial advice? • are they aware of support that the organisation may provide such as reference to occupational health, counselling< employee Assistance Programme (EAP), brief therapies, health checks? • is there any aspect of their medical care that it would be helpful for you to know about? (For example, side effects of medication that might impact on their work) While you have no right to this information, the employee should be aware that you cannot be expected to make 'reasonable adjustments' under the terms of the DDA if you are not informed about the problem
Issues to raise with an employee who is distressed • Does the employee have ideas about any adjustments to their work that may be helpful? these could be short or long term • Do they have any ongoing mental health problem that it would be helpful for the manager to know about? If so, is it useful to discuss their established coping strategies and how the organisation can support them? (See section 7 for more information). It is the employee's choice whether to reveal this. But you cannot necessarily be expected to make reasonable adjustments for a condition if you don't know it exists. • Establish precisely what they wish colleagues to be told and who will say what. Any inappropriate breach of confidentiality or misuse of this information might constitute discrimination under DDA • Agree what will happen next and who will take what action • You might also consider whether the employee has been affected by an issue that may affect others in the team, organisation? If the latter then you need to undertake a stress risk audit followed by team based problem solving. Discuss this with your H&S department, (you might consider bringing in someone from outside the department or an external expert to help) • It is important that you record all conversations accurately - not just to protect the organisation and the employee, but also to show that the actions have been carried out fully.
Managing an employee who becomes tearful and upset • This can happen for any number of reasons and can be connected to something at work or outside work. • Reassure them that it is OK to be upset and that you are listening. In fact, the proccess of listening may provide an important space for both you and the employee to gain insight into the problem and possible actions and, • Ask if they would like someone of their choice with them • Try to be sensitive to the level of information and support the individual can cope with at a given time. In the midst of a crisis they may not be able to think clearly and take on board complex information. The important points are to talk to them, reassure them their job is safe, state positively that all help, assistance and support will be offered, and affirm that discussion will continue at a pace that suits them. Try and be calm yourself!
Managing an employee who becomes tearful and upset Managing the rest of the team. Be aware of the impact one employee's mental health problems could have on the rest of the team, whether as a result of reasonable adjustments that have been made or because of the person's particular symptoms or behaviour while unwell. Recognising when professional/clinical help is needed If someone remains unwell despite support then you should encourage them to seek appropriate help. Consider referral to your occupational health department if available with their written, informed, consent or encourage them to see their own GP. You might also be able to help them to make an appointment and even go with them to the surgery - if they wish this.
Communicating with colleagues You should agree with the person whether and precisely what they wish colleagues to be told. In general it is best to talk to someone experiencing mental health problems in an honest, matter of fact way - that is in the same way you would deal with someone's physical health problems. If the person takes sick leave you should ask whether they want to be visited, receive flowers and cards or not and respect their wishes. The person's requests may change over time. If they initially request little contact, this may change as their mental health improves. As far as possible, someone with a mental health problem should be treated in exactly the same way as any other sickness absence. Proactive health promotion Some employers find that access to talking therapies and company funded counselling schemes provide a safe space for staff to explore emerging problems before they become acute.
Keeping in touch during sickness absence • Managers often fear that contact with someone who is off sick will be seen as harassment. However, the overwhelming view from people who have experienced mental distress is that appropriate contact is essential. Employees should be informed that they too have a responsibility to keep in contact. Supporting an employee who is off sick • • • • • It is essential to keep in touch. Many managers are hesitant about this in case they say the wrong thing or are perceived to be hassling. However, if there is little or no communication, misunderstanding and barriers can quickly arise, then the employee may feel that they are not missed or valued and this can exacerbate already low self esteem. inviting them to social events will show that you still think of them as one of the team. you should reassure them about practical issues such as their job security and deal with financial worries give the employee the chance to explain the problem and what is happening by asking open questions. ask if there is anything you as their manager can do to help reassure them that you understand medical and personal boundaries and will respect them review their needs/ whishes for support
Keeping in touch during sickness absence • • • • Supporting an employee who is off sick depending on the severity of the illness, explore if it would be helpful to have a half way house between work and absecence such as working for a couple of hours a day at home plan a phased return to work as they approach fitness for work, and it is helpful to think about the support you would offer to someone with a physical problem. Do you have a different approach for stress/mental distress, and, if so, why? Visiting in hospital, cards, flowers etc can be appreciated - but ask. The bottom line is to let people know they are not forgotten. Don't make them feel their problem is shameful. Avoid: putting pressure on the person to divulge personal or medical information - it is their choice to reveal this or not, and putting pressure on them to name a return date. When someone is in crisis it may be impossible for them to know how long recovery will take. Deadlines will only add to the pressure.
Keeping in touch during sickness absence Contact with GPs If the employee does not wish you to contact their GP, that is their absolute right. If you have access to occupational health, these professionals should be involved over any health problems that may affect their ability to work and where work and job adjustments may be required. What to do if the person requests no contact This is not uncommon and the worst thing you can do as a manager is to accept it at face value and send all contact with the individual - all the evidence shows clearly that this hinders the person's recovery and greatly reduces the chances of a successful return to work. People may request no contact because they feel embarrassed or ashamed about the way that they feel and are behaving - a sympathetic manner and treating the person normally can help to overcome that. Sometimes the request for no contact arises because you, the manager, are perceived to have been a factor in becoming unwell. In such circumstances, options include offering the services of another manager and/or making use of an intermediary such as a colleague, family member or trade union official. If there are work issues (real or perceived) it is essential that these are addressed or it will be unlikely the person will return to work. You may wish to revisit this tactfully. As the person begins to recover, contact may seem less daunting.
Returning to work Most people with mental health problems recover completely and have the capability to resume work successfully. The organisation has made an investment in that individual and in most cases, a planned return to work will be more cost effective than early retirement. Effective planning - between the individual and the line manager and, where appropriate, involving other sources of support such as the GP, occupational health or HR - will maximise the chances of success. So will support and monitoring at the early stages of return. Factors to consider in planning the return You should consider with the employee any factors that contributed to their absence that could realistically be changed or accommodated. You must make sure the employee doesn't return to an impossible in-tray and thousands of emails. When they return, brief them on what's been happening - social life as well as work developments. Be realistic about workloads - be aware that some people will wish to prove themselves and may offer to take on too much. Instead, set achievable goals that make them feel they are making progress. Take the time to have frequent informal chats so there is opportunity to discuss progress/problems without a formal (and possibly intimidating) session.
Returning to work Give positive and constructive feedback. You will also need to discuss honestly the things you can change and those you can't. Some organisational factors are out of your control. You might also consider a mentoring scheme with another employee so that the person returning can also talk to someone who isn't their manager. Above all make sure you and team make the person feel welcomed back. Avoid: • • making the person feel they are a social case - this can cause resentment both with the individual and with peers, and failing to deal with their work whilst they have been off work. Check whether a backlog of unfinished work has built up and deal with this also. Be aware: • If the employee is on medication they may experience distressing side effects. They may or may not feel able to discuss this with you. However it may be helpful to consider that it can be easy to confuse side effects with the illness. Any effects on work may be temporary and or the person may only take medication for a short time. It is important they continue with their medication until they have discussed this with their mental health physician. You also need to ensure that any side effects are considered against their job requirements. this is particularly crucial in jobs where there are health and safety risks.
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