Stress management: Strike out stress

There is an increased recognition that stress reduces productivity at work in several ways – for example, by affecting the ability of staff to perform their roles effectively, and increasing absence rates. But a study of people who voluntarily attended a group training course on stress management and assertiveness based on cognitive behavioural therapy (CBT) at Flintshire County Council shows the importance of dealing with stress holistically, rather than separating home and work lives.

Participants included people for whom stress had caused long-term absence from work, including employees under investigation and involved in disciplinary actions. Those who were recently bereaved or had no insight into their problem were excluded from taking part. Twenty-one staff participated (17 women and four men) with ages ranging from 25 to 61 (mean: 46 years).


The CBT training consisted of eight weekly sessions, each lasting an hour-and-a-half. Course content included:

  • The physiological symptoms of the stress response

  • The relationship between negative thoughts and mood change

  • The role that conditioning and rigid beliefs play in forming attitudes and interpreting events

  • The influence of mood on behaviour

  • Identifying unhelpful coping strategies, such as alcohol, smoking or eating disorders, and replacing them with more helpful ways of coping with stress

  • Relaxation techniques and time-management training

  • Techniques that help reduce stress or the causes of it

  • Assertiveness skills to improve communication.

During the course, each participant was provided with:

  • A ‘Life Events Inventory’ to help normalise and recognise the significance of events on stress-related health problems

  • An ‘Effects of Stress’ questionnaire to identify areas of personal stress

  • A ‘Ways of Coping’ questionnaire to recognise strengths and areas of weakness for development through assertiveness training

  • A ‘Hospital Anxiety and Depression Score’ (HADS) questionnaire – a self-screening tool completed at the beginning and end of the training course

  • A stress level assessment completed at the beginning and end of the training programme

  • An evaluation form.


Analysis of the course results found that a range of issues were causing stress among the participants, including:

  • Bereavement

  • Change of career

  • The disciplinary process

  • The end of long-term relationships

  • Health-related concerns

  • House floods

  • House moves

  • Increases in workload

  • Managing children with challenging behaviour

  • Management restructure

  • Road traffic accidents

  • Witnessing a violent incident.

The ‘Life Events’ were found to contribute to mental health issues, with a number diagnosed among the participants:

  • Adjustment disorder: 9 participants

  • Depression: 2

  • General anxiety: 2

  • Mixed depression and anxiety: 3

  • Emetophobia: 1

  • Insomnia/Health anxiety: 1

  • Obsessive compulsive disorder: 1

  • Post-traumatic stress disorder: 1

  • Stress: 1

There were improvements on the HADS scores by the end of the course:

  • Beginning average scores of first HADS questionnaire: Anxiety 13.1 Depression 9.5

  • End average scores of second HADS questionnaire: Anxiety 9.2 Depression 5.1

Likewise, stress level scores were also reduced: the average score at the beginning of the course was 61, and on completion it was 32.

The data from this assessment confirmed that there was strong interaction between work and home lives. For the majority of people, while the stress was actually associated with changes at home, the effects crept into their work lives.

When stress is triggered by work, organisational change is the primary cause, and changes in workload can also trigger work-induced stress. Participants assessed their levels of stress to be much lower immediately following completion of the course.


According to research reported in Personnel Today (4 Dec 2007): “reliance on techniques such as cognitive behavioural therapy (CBT) is backed by evidence of clinical effectiveness… One 2006 study by the London School of Economics claimed a £750 course of CBT was both cheaper and more effective than drug-based solutions”.

To provide CBT to 21 employees individually (at a cost of £750 per person) would amount to £15,750. However, the provision of a group course of CBT meant that the cost for the training course was £800 (£100 per session.) This figure was based on two-and-a-half hours of the trainer’s time (which takes into account preparation of the training room and cost of photocopying handouts), making the cost to the employer £38 per employee for 12 hours of CBT training.

There are other things to take into consideration when introducing a CBT course. The government has called on businesses, occupational health (OH) and the medical profession to come up with ideas on how to improve the health of the UK working population, in response to Dame Carol Black’s review of the health of working-age people. Key elements of the Black review include:

  • How can we keep working-age people healthy, and how can the workplace be used to promote health?

  • What underlies the apparent growth in mental health problems in the working-age population, and how can this be addressed?

  • What constitutes effective OH provision, and how can it be made available to all?

This study shows the importance of dealing with stress holistically. The clinical separation of home and work lives is unrealistic, and there are some crucial lessons in this for managers who need to be adept in the identification of the life factors that are likely to trigger stress.


The provision of support once stress has already been identified was the core of this study. However, it may be that the provision of ‘just in time’ support for those on the cusp of stress might also be effective. This could be linked to an initiative to help managers identify stress earlier. Teaching some of the techniques designed to reduce stress could be included in routine skills refreshment for all employees. Prevention is better than cure.

This study showed immediate effects, but the data to demonstrate improved work-related performance or lower long-term stress is not yet available. This information would be helpful in providing a longer-term perspective on the effectiveness of the course.

Dr Peter J Oliver is a consultant occupational physician and Linda Lewis is OH nurse manager at Flintshire County Council. Mo Pollitt, a cognitive-behavioural therapist, devised and ran the group Stress Management and Assertiveness course while Linda Lewis acted as monitor.

Measures for stress

  • Holmes, T & Rahe, R (1967) Life Events Inventory. Journal of Psychosomatic Research, 11, 213-218

  • Powell, T (2003) Effects of Stress questionnaire. Mental Health Handbook

  • Powell, T (2003) Ways of coping questionnaire. Mental Health Handbook

  • Snaith, R P (2003) Hospital Anxiety and Depression Scores (HADs). Licensee BioMed Central Ltd


  • American Psychiatric (1994) Diagnostic and Statistical manual of mental disorders (4th ed.) DSM 1V Washington, DC. APA

  • Crail, M. (2007) Research update: Most employers fail to tackle stress at early stage Personnel Today, 4 December 2007, p47

  • Paton, N. (2007) Government seeks contributions to improve health of UK workers. Occupational Health, November 2007, Volume 59, number 11, p5

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