Stress Management and Workplace Disability in the US, Europe and

Journal of
Occupational Health
J Occup Health 2003; 45: 1–7
Review
Stress Management and Workplace Disability in the US, Europe
and Japan
Deborah L. JONES1, Takeshi TANIGAWA2 and Stephen M. WEISS3
1
Department of Psychology, Barry University, USA, 2Institute of Community Medicine, University of Tsukuba,
Japan and 3Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine, USA
Abstract: Stress Management and Workplace
Disability in the US, Europe and Japan: Deborah L.
J ONES, et al. Department of Psychology, Barry
University, USA—Although the health care costs and
the number of disability cases across all medical
illnesses have increased, disability management
programs implementing stress management
interventions have been found to improve physical and
mental health, reduce costs to employers, and facilitate
the reintegration of injured individuals into the work
environment. Stress management programs limit the
impact and chronicity of disabilities and can be used
to reduce and control the cost of disability in the
workplace. Providing the most efficacious behavioral
interventions thereby allows employers, employees and
health professionals to work cooperatively to achieve
optimum health and cost effectiveness. This review
presents a variety of group and individual interventions,
which have been utilized to aid disabled employees in
coping with work-related injuries and medical illness.
The implementation of stress management
interventions in the workplace is described in detail,
with special emphasis on the use of cognitive
behavioral stress management. Finally, this review
outlines a team approach to the application of a
workplace stress management intervention aimed at
reducing the overall impact of disability.
(J Occup Health 2003; 45: 1–7)
Key words: Stress reduction, Cognitive behavioral
stress management, Intervention study, Disability,
Workplace
Stress Management is a psychoeducational program
for dealing with stress in which individuals are taught to
become aware of their appraisal of stressful events
(positive, negative, surmountable, impossible) and to
Received Jan 24, 2002; Accepted Oct 9, 2002
Correspondence to: T. Tanigawa, Institute of Community Medicine,
University of Tsukuba, 1–1–1 Tennodai Tsukuba-shi, Ibaraki 3058575, Japan
develop methods for more effective coping (e.g.,
managing problems efficiently and with less stress1)).
Stress management interventions utilize a variety of
techniques, including self-management skills, relaxation
training, biofeedback, behavior modification, cognitive
behavioral therapy, social support, emotional expression,
and physical activity, such as exercise and yoga2). Group
and individual stress management interventions are
designed to improve coping skills, increase selfconfidence and reduce vulnerability to distress.
Stress management is also an integral component of
health promotion in the workplace3) and is an element of
many workplace disability programs. Interventions
implemented early in the course of disability have been
found to greatly reduce the amount of time needed away
from work4–6) and to reduce the potential for chronicity7, 8).
Stress management programs limit the impact of
disabilities and can be used to reduce and control the
cost of disability in the workplace. Workplace stress
management programs for individuals with disabilities
include patient education and support groups that focus
on improving quality of life (e.g., fewer symptoms, better
functioning, less pain) and reducing the adverse effects
of medical treatment (e.g., less pain from procedures, side
effects of medication, anxiety). Stress management
interventions have been developed for a variety of
disorders, including musculoskeletal injuries and
disorders (back pain 7, 9) , neuromuscular disorders
(multiple sclerosis10)), immune system disorders (HIV11)),
chronic fatigue syndrome12, 13), arthritis14, 15)), high blood
p r e s s u r e 16), h e a d a c h e 17) a n d m i g r a i n e 4–18) a n d
psychological distress19).
Cognitive behavioral stress management (CBSM)
interventions combine stress management techniques with
cognitive strategies. The cognitive behavioral component
was developed to teach individuals various forms of active
coping strategies (e.g. cognitive restructuring including
re-framing, thought replacement and challenging
irrational thoughts, relaxation techniques, and
2
assertiveness training). Generally, coping strategies
categorized as active-behavioral strategies (e.g., planning,
seeking social support) or active-cognitive strategies
(finding meaning in an illness, cognitive re-framing) are
associated with a more positive affect and higher selfesteem in various populations dealing with chronic
illness20–23). Conversely, denial and avoidance coping
strategies (denying the illness, avoiding situations,
persons or medical treatment that are related to the illness
or disability) are associated with greater depression and
distress25–27).
Cognitive behavioral self-management interventions
have been shown to be effective means of managing
several types of illness including HIV/AIDS24, 28), chronic
pain29), migraine18), chronic fatigue syndrome13) and carpal
tunnel syndrome30). Cognitive-behavioral interventions
have been used with to a) decrease depression and anxiety
b) increase social support and c) teach more effective
coping and stress-reduction strategies 32). Cognitive
behavioral skill training has been demonstrated to
improve health status, reduce substance abuse behavior,
and improve quality of life11, 31, 32). In addition, unlike
more cognitively complex models, e.g., psychodynamic
therapy, cognitive behavioral skills are also more rapidly
understood and integrated by patients at a variety of levels
of intellectual and educational attainment.
Application of the Stress Management Intervention
to Workplace Disability.
Stress management workplace interventions designed
to meet the needs of those with disabilities focus on selfmanagement of illness and injury. Most self-management
programs include stress management, pain and illness
management and exercise and nutrition plans. Stress
management programs include three successive
components, typically taught over a 6 to 10 wk period.
Participants are first taught to identify stress and stressors
(education phase). Next, participants learn cognitive
skills aimed at improving coping with stress (skills
acquisition phase). Finally, participants practice stress
management techniques in targeted situations while
monitoring their effectiveness (practice phase33)).
Education Phase
The first phase of stress management for disability
group intervention emphasizes social support; participants
meet with other individuals having disabilities similar to
their own. Social support obtained from participating in
psychological interventions has demonstrated improved
outcome in disabled populations (cancer34)). Participants
learn that stress can negatively affect the progression of
their illness or disability and its eventual clinical outcome
by causing psychological and biochemical changes (e.g.,
immune suppression, decreased depression11, 33)).
Patient education and social support have been
J Occup Health, Vol. 45, 2003
demonstrated to provide health and cost benefits in
dealing with minor and acute illnesses, psychosomatic
and stress-related disorders, chronic pain, diabetes,
a s t h m a , a r t h r i t i s , s u r g e r y a n d c h i l d b i r t h 35).
Psychoeducational interventions have been developed to
treat patients throughout the lifespan presenting with
arthritis 14, 15, 36, 37) , cancer 38–41) , chronic illness 31) ,
hypertension22), chronic fatigue13, 42), chronic pain31, 43, 44)
and back injury5).
Cognitive behavioral education component. Cognitive
behavioral strategies are taught that will provide the
employee with such skills as cognitive re-framing,
problem- and emotion-focused coping, assertiveness and
anger management and promote attitude change45, 46).
Cognitive re-framing, examining thoughts, opinions or
beliefs from a different perspective, enables the patient
to challenge existing ideas that may be generating
negative emotions (e.g., living with a disability “one day
at a time” rather than “for the rest of my life,” developing
a revised view of the self as a productive member of the
workforce).
Skills Acquisition Phase
In the skills acquisition phase, participants are taught
to observe their behavior and record the most stressful
situations, while noting physical, emotional and
behavioral reactions to stressors. They are also
encouraged to record their maladaptive responses to
stressors (e.g., increased smoking and substance use,
decreased sleep and exercise47)) in a stress diary. In this
phase, participants are taught to examine the role of their
disability as a stressor. In addition, they note the
antecedents of their reactions to stressors, focusing on
events occurring immediately prior to feelings of stress
(e.g., feelings of anxiety may be preceded by doctor
visits). Group discussion focuses on negative internal
monologues about the disability that may lead to irrational
feelings when faced with disability-related stressors, and
the contribution negative monologues may make to
feelings of stress (e.g., “I can’t do anything anymore; I’ll
never be able to function normally again” may lead to
feelings of depression or hopelessness48). Skills acquired
may consist of cognitive behavioral self-management
techniques, time management skills and behavioral
regulation strategies, including relaxation training and
nutrition and exercise plans.
Cognitive behavioral skills. Participants are taught to
apply problem-solving skills that are appropriate to the
problem situation (e.g., applying problem-focused coping
skills to problems that can be solved by personal action
and applying emotion-focused coping skills to problems
that must be emotionally tolerated because they have no
potential solution.) Assertiveness training is used to teach
Deborah L. JONES, et al.: Stress Management and Workplace Disability
employees to stand up for their rights by learning to
express their thoughts, feelings and opinions without
infringing on the rights of others. Assertiveness training
for the workplace relies on developing communication
skills such as saying “no” or using “I statements”,
responding to others’ specific behavior in terms of its
impact on the individual’s emotions, e.g., “I feel
disrespected when you criticize my physical limitations.”
Finally, anger management focuses on applying cognitive
behavioral skills to enable the individual to recognize
situations that trigger anger and engage in more
constructive expressions of anger, such as using “I
statements”, e.g., “I was angry when my contribution was
not acknowledged.”
Relaxation Training. Relaxation training is a
behavioral self-management skill designed to affect the
physiological experience of stress by reducing
physiological arousal (the stress response) and increasing
the parasympathetic (calming) response48, 49). Examples
of relaxation training include progressive muscle
relaxation, guided imagery, meditation or meditative
relaxation, yoga and hypnosis. Progressive muscle
relaxation (PMR 49)) teaches participants to recognize
feelings of tension and relaxation by having them tense
and then relax muscle groups throughout the body. PMR
may be combined with diaphragmatic breathing exercises
to deepen the feelings of relaxation, and is used selectively
with disability patients having chronic pain or muscle or
tissue injury. Meditative relaxation50) combines muscle
relaxation with quiet surroundings, a comfortable body
position, a repetitive sound (such as “Om” or “peace”)
and a passive attitude. Participants sit with muscles
relaxed and focus their attention on each breath while
repeating their sound. Attention to the sound maintains
muscle relaxation. Participants with pain-related
disabilities often have difficulty in a seated posture, and
may also complete this exercise in a reclining position.
A similar method, mindfulness meditation51), was derived
from Buddhist meditation practice, and incorporates
mindful awareness of thoughts and sensations arising
while focusing on the breath or a sound. Participants are
encouraged to simply become aware of their thoughts
regarding their pain or disability without judging the
content, enabling them to become aware of their response
to their perceptions. This technique has been used
effectively in the self-regulation of pain52) and was found
to be more effective than physical therapy, medication
and antidepressants, resulting in decreased use of
medication and increased physical activity. Finally,
guided imagery, similar to meditative relaxation, teaches
participants to replace periods of pain or distress with
peaceful images such as the rhythmic movement of the
ocean. Once patients have learned to relax, they are
instructed to practice independently at home. The concept
3
of homework is integral to stress management, as it allows
the participant to master concepts learned during group
or individual sessions.
Practice Phase
The final phase of stress management, practice,
facilitates the application of problem-solving techniques
to stressful situations as they arise, encouraging
participants to assess the efficacy of the techniques and
revise their goals as needed. Cognitive self-management
techniques utilized may include positive re-framing, goal
setting and behavior modification. Participants are
encouraged to complete behavioral homework
assignments and may establish contingency contracts to
facilitate behavior modification. The goal of behavior
modification is to shape behavior, rather than to remove
feelings of pain or discomfort53). Behavior is modified
by identifying pain reinforcers, stimuli that increase the
likelihood that pain behavior will be repeated. This final
phase of stress management is designed to inoculate the
individual from disability-related stress54).
Cognitive behavioral practice. Employees are
encouraged to apply skills learned in sessions to present
situations in the workplace, home or social interactions.
For example, an employee experiencing chronic back pain
might learn a problem-focused strategy, such as asking
for assistance with lifting, and an emotion-focused
strategy, such as emotional acceptance of physical
limitations. Assertiveness training skills are applied to
employee defined problem situations, allowing employees
to return to group and discuss outcomes. Additional
consideration is given to employees presenting with issues
such as domestic violence, which may require special
intervention or concerns regarding assertiveness in the
home.
Stress Management in the Workplace: Application
and Effectiveness
Worksite disability management can include
prevention, wellness and safety programs, employee
assistance programs (EAP) and return to work programs.
Ideally, such programs are designed to instill a sense of
teamwork and to provide measurable outcomes.
Psychologists play a key role in the development of
disability management interventions, which are frequently
multidisciplinary and comprise various components.
These psychological interventions may range from
informational and psycho-educational wellness and safety
programs (e.g., stress management) to more sophisticated
programs including individual directive (behavioral,
cognitive and cognitive behavioral) and non-directive
(supportive or dynamic) therapies.
The utilization of psychologists in disability
management plays an additional role in the prevention
4
of work-related disability through a proactive strategy
that focuses on early identification of environmental
(workplace), social, psychological and physiological
factors that may lead to eventual disability. The
combination of psychological and medical care
techniques can improve outcomes in disability
management and assist businesses in remaining
competitive so that reducing medical expenses and time
off the job offset the cost of behavioral interventions such
as stress management55).
The integration of psychologists into the workplace
through disability management programs can assist both
the employee and employer. Psychologists can aid
injured/disabled employees in adjusting to their ailment,
and assist employers through the provision of education
and information. Psychologists can also provide psychoeducational training services to management and staff
on topics such as stress management and disability-related
matters. Through the collaboration of psychologists,
employees, and employers, stress management programs
can facilitate improved physical and mental health in a
cost-effective manner.
There is considerable evidence that worksite stress
management programs are cost effective. For example,
stress reduction interventions reduce the effects generated
by stress (e.g., hypertension, increased endocrine levels,
immune suppression, increased susceptibility to illness),
and the behavioral changes that affect physiology, (e.g.,
increased smoking and substance use, decreased sleep
and exercise47)). Large-scale studies have demonstrated
disability cost reductions based on decreased medical
utilization55, 56) and reduced absenteeism57). A review of
stress management interventions in the workplace found
the most positive results across the various health
outcomes were obtained with a combination of two or
more techniques. Nevertheless, the great variety of stressmanagement techniques in combination with the wide
range of health outcome measures used in stress
intervention studies prevents specific conclusions about
the efficacy of each technique and each outcome. Stress
management in the workplace is effective in enhancing
health, but the choice of which technique is appropriate
must be based on the specific disability and health
outcome targeted for change60).
Stress management for disabilities in the workplace is
a psychological intervention aimed at reducing the human,
social and economic cost of disability to workers,
employers and society. Early psychological interventions
improve disease prognosis and overall functioning 4).
Similarly, psychological/educational interventions for
back pain9) and lower back pain have found continued
activities7) and a combination of clinical and occupational
interventions6) to result in a faster return to work, less
chronic disability and fewer recurrent problems7–9). The
cost effectiveness of stress management techniques has
J Occup Health, Vol. 45, 2003
been illustrated with a variety of disabilities.
1. Decreases in clinic visits (36%) and in anxiety, hostility
and depression were obtained with group behavioral
interventions aimed at the control of chronic pain. The
intervention consisted of 10 × 90 min weekly group
meeting (physiology of pain, medical and behavioral
treatments relaxation, yoga, communication skills, goal
setting, problem solving, cognitive restructuring and
homework exercises) 35).
2. Decreases in the length of hospital stay for surgical
patients (1.5–2 d) were obtained with an intervention
aimed at providing 1) health care information, 2) skill
building exercises including relaxation and 3)
psychosocial support building35).
3. Patients with psychosomatic symptoms comprise
approximately 60% of visits to medical practitioners
in the US. Improved health outcomes were obtained
from a mind-body intervention on behavioral change
vs. an information only condition, resulting in decreases
in medical office visits over 6 months. The intervention
consisted of educational materials, relaxation-response
training, awareness training, and cognitive
restructuring, 90 min × 6 wk35).
4. Thirteen to fourteen million individuals in the US have
a history of coronary artery disease; 1.5 million
individuals each year experience a myocardial
infarction, of whom one-third die, half of whom do so
within 60 min of the event. The total cost of
cardiovascular disease was $18 billion in 1994.
Cognitive behavioral stress management interventions
targeting “Type A” high stress individuals have been
used to decrease the risk of myocardial infarction (MI).
In addition, nutrition and fitness interventions are often
d e s i g n e d t o t a rg e t p o t e n t i a l l y d e b i l i t a t i n g
atherosclerotic vascular disease35)
Workplace disability management teams (e.g.,
physicians, nurses, psychologists, occupational therapists,
social workers, physical therapists) represent a taskforce
within the workplace devoted to prevention, wellness19)
and safety programs and return to work programs, as well
as rehabilitative care58). Team members are integral to
the implementation of stress management interventions
for workplace disability. Team members can utilize
cognitive behavioral stress management interventions to
enhance worker productivity and satisfaction by
developing group and individual interventions. In
addition, team members can support injured and disabled
employees during adjustment to their disability, and
facilitate employer-employee relations by providing
education and training services to management and staff
on disability-related matters. Examples include: 1)
training workplace managers as well as general staff
members regarding disabilities and their occurrence in
the workplace to enhance comfort in addressing health
Deborah L. JONES, et al.: Stress Management and Workplace Disability
issues actively and proactively59), 2) training to facilitate
the development and maintenance of a supportive
atmosphere for recovery, and 3) training on reintegration
of the disabled employee in the workplace.
Smaller companies may lack the resources necessary
to establish a disability management team, and may
establish alternative external resources for providing
health care services, including referrals to outside
agencies or community health centers. Many companies
offer counseling services; of employers surveyed, 32%
of small businesses (under 100 employees), 54% of
medium sized businesses (100–500 employees) and 71%
of large businesses (over 500 employees) offered
counseling61). In addition, a variety of publications and
audiovisual materials are available for large and small
businesses seeking to develop and implement health care
stress management interventions62, 63). Finally, Employee
Assistance Programs (EAPs), on- and off-site as well as
on line, offer stress management programs 64, 65). In
addition, community health centers offer stress
management programs for a variety of disabilities.
The importance of stress management programs and
their integration in the workplace has become an
international issue35, 62, 63, 65–69). Although the health care
costs and the number of disability cases across all medical
illnesses have increased, disability management programs
implementing multidisciplinary interventions including
stress management have been shown to improve physical
and mental health, reduce costs to employers, and
facilitate the reintegration of injured individuals into the
work environment. Group and individual interventions
have been effectively utilized to aid disabled employees
in coping with work-related injuries and medical illness.
Multidisciplinary interventions, primary, secondary and
tertiary prevention programs and interventions for specific
populations provide a comprehensive and effective
approach to disability management. Future interventions
should be designed within a theoretical model, targeting
the workplace environment by addressing individual and
organizational factors, increasing worker involvement,
assessing stressors and evaluating health and cost efficacy
measures60, 70) In addition, interventions should respond
to culture, gender and job type-specific issues that may
moderate workplace stress 71–75). Providing the most
efficacious stress management interventions ultimately
allows employers, employees and health professionals
to work cooperatively to achieve optimum health and cost
effectiveness.
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