Extensive research provides evidence demonstrating the effectiveness of cognitive behavioural therapy (CBT) in treating a range of mental health conditions. The National Institute for Health and Clinical Excellence (NICE, 2004) recommends CBT as a primary intervention for depression, anxiety disorders and post-traumatic stress disorder.
The British Occupational Health Research Foundation (BOHRF, 2005) recommends it as the treatment of choice for helping people with common mental health problems to remain in the workplace and make an effective adjustment to health and productivity. The BOHRF guidelines encompass prevention of common mental health problems, retention at work and rehabilitation, providing clear recommendations for practice, while also suggesting other interventions worth considering.
Dame Carol Black's review of health and work in 2008 highlights the fact that occupational health (OH) is facing a time of change and development, and there is a clear role to address work-related stress. Practitioners are expected to use techniques and skills with proven effectiveness to encourage wellbeing at work and help reduce sickness absence. As work-related stress symptoms commonly present to OH, effective management of this condition is imperative.
With sound evidence-based guidelines extolling the benefits of CBT, OH must consider incorporating it in an effective format into its regular practice, as a tool to address work-related stress.
Cognitive behavioural therapy
CBT can be used at all stages of intervention, from primary/preventative work to secondary and tertiary approaches. The role and use of CBT has clearly arrived in the OH arena.
After initial meetings with management, a large acute foundation NHS trust with about 12,000 staff developed an outline plan for CBT clinics within the OH departments, offering CBT skills to staff presenting with work-related stress symptoms. This was in addition to an existing independent counselling service available for employees to self-refer to for a limited number of counselling sessions. An OH adviser, with previous counselling skills training and experience, completed a suitable CBT training course.
The proposal was two-fold. First, to provide sessions on all three major trust sites on a fortnightly basis. To ensure that referrals to these clinics were appropriate, all clinical staff at the OH department attended a one-day training course providing an overview of CBT. This facilitated the development of assessment skills to identify clients who were likely to benefit from specific CBT techniques to help address work-related stress issues.
The second part of the proposal related to developing stress management study days for staff to attend, as a proactive approach to address potential work-related stress issues. Initially, it was agreed to target senior staff. To date, four study days have taken place and been well-evaluated. Further study days are planned, and further plans include the expansion of these days to be available to all employees.
A referral process was developed, deciding that self-referrals were not acceptable. An initial assessment was considered necessary to avoid inappropriate clients attending the service. Such clients would be advised of other, more appropriate, services when attending this initial assessment appointment with OH staff.
Employees, whether self- or management-referrals, attend a booked appointment with an OH adviser or physician (who had previously attended CBT basic one-day training). During this appointment, the stress triggers are discussed. Suitable advice to management about how to help resolve the issues in the workplace is provided, and the OH practitioner decides if referral to the CBT sessions is appropriate.
A referral form for the CBT sessions was developed. The completed referral form is received by the adviser providing the CBT sessions, who then sends an appointment date to the client.
Information sheets were written and produced for OH staff and clients. A staff information pack containing instructions about assessment of the client, the referral process, referral form and the information fact-sheet for clients and the pack was sent to each OH department. This client fact-sheet was written for the employee considering CBT to read before the sessions. It can also be given to those considering attending but who remain unsure.
The service dates were planned and an article was written for the trust's local staff magazine to introduce the service.
It was agreed that employees could receive six CBT sessions within a 12-month period. While these were planned as fortnightly, some clients chose longer breaks between appointments to undertake some homework assignments and exercises.
Clinical supervision of such CBT practice is essential and of paramount importance.
The service has been in operation for eight months. The six sessions of CBT take place over a 12-week period but, at the request of the employee and allowing for the flexibility of CBT, this has frequently taken place over a longer period. There is, therefore, only limited data to present at this point.
Currently, four appointments on each of the three sites are provided, allowing for a maximum of 12 appointments a fortnight.
A relationship with an appropriate counselling supervisor has been developed to provide this on an ongoing basis. This has proved an effective technique, providing support for the OH adviser, while guiding good evidence-based practice.
Clients complete a tick-box questionnaire at their first session, addressing how they have been feeling during the previous week. A more detailed questionnaire is completed at the end of a course of sessions. This is used to evaluate the sessions from the client's perspective. An external counselling agency will undertake this work using a software programme and provide feedback to the OH department (see box).
While this clinic was developed to address work-related stress, it is recognised that home-related stress issues affect people's mental health and functioning at work, so these issues are addressed too. Somatic symptoms addressed have included insomnia, headaches, stomach cramps and musculoskeletal pain. The service is audited for process, quality and outcome (for example, waiting times to be seen, client satisfaction, and return-to-work outcomes.)
It is thought unlikely that the CBT interventions will have a lifelong effect, so booster and follow-up sessions are proposed for future practice, with the aim of sustaining the changes developed from CBT work. Longitudinal studies would be interesting to ascertain long-term benefits. This has yet to be developed within this clinic. No such studies are known of by this author.
With cost-effectiveness of interventions an important issue, further ongoing research is recommended in the effectiveness of CBT and a cost-benefit analysis of CBT techniques and other approaches. The introduction of effective CBT interventions will be challenging for many, requiring commitment from both employee and employer, and the involvement of unions and welfare organisations. It is worthwhile for the culture of an organisation to embrace and foster changes and interventions with proven effectiveness.
Joseph Buggy is specialist practitioner in the OH department of East Kent Hospitals University Foundation Trust.
Black, C. (2008). Working for a Healthier Tomorrow. London: TSO
British Occupational Health Research Foundation. (2005). Working Interventions for Common Mental Health Problems.London: BOHRF Publications
National Institute of Clinical Excellence. (2004). NICE Guidelines. London: NICE Publication.