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Chapter 1
Work as a Potential Source of Meaning versus of Stress: Implications for Mental Health
According to Professor Dr. Viktor Frankl, psychiatrist and neurologist, the human being’s foremost quest is for meaning, without which life becomes empty, a void. Frankl considers lack of meaning to be the primary cause of psychological distress in the modern era [Frankl 1963]. Professor Frankl founded the school of “Logotherapy,” based upon the premise that finding and creating meaning in their lives will help patients recover from various manifestations of mental ill-health.
One of the most important potential sources of meaning in life is through work. Work can help fill a human being’s life with a sense of achievement, with dignity and with a structure. Work is one of the ways by which human beings can feel that they have made a difference, that it has mattered that they have been alive. To paraphrase Professor Bertil Gardell [1987], a pioneer in the efforts to humanize the work environment: work is one of the most important potential sources of social and psychological well-being, which can provide much of the meaning and structure in adult life.
On a much more obvious level, the majority of adults depend upon their work in order to survive, to meet their own needs, as well as those of their families, to earn their “daily bread.” In that sense, having a stable job is the basis of a secure life, which besides being essential for bare biological existence, can contribute to psychological well-being.
Unfortunately, however, a large number of jobs fall short of this potential. Rather, the contemporary work environment has all too often become the locus in which employed people spend many of their waking hours performing activities that are demanding, constraining, and otherwise stressful. Some work activities may even seem pointless.
Reflecting pressures of global competition, trends in working life are towards increasing job demands, longer working hours and job instability. Growing dependence on computer technology, which could improve working life, has actually led to heavier workload and increased pressure. The toll of unhealthy work upon mental well-being is a primary concern.Professor Dr. Lennart Levi, one of the founders of stress medicine, considers that work-related mental health problems are among the major causes of morbidity and premature death in much of the developed world [Levi 2006].
What can a clinician do to help solve these problems?
That is the theme of this book. |
1.1 The Need for an Integrative Clinical Approach
Besides conventional biomedical therapy directed towards the cure or at least palliation of disease, a more integrative clinical approach is increasingly aimed at promoting a healthier balance between the patient and his or her surroundings. Particularly with regard to mental health disorders, it is coming to be appreciated that ill-health has not only biological but also psychosocial determinants.
The roots of such an integrative clinical approach have existed since antiquity. Now, with the expansion of our scientific sophistication, the possibilities are fully at our reach to much more deeply explore the enormous complexity and innumerable interconnections among the environment, the human nervous system and the target organs affected by disease.
Notwithstanding these insights, we still very frequently miss the mark. Namely, we too often fail to realize that the fundamental source of the patient’s psychological distress is beyond the strictly biomedical domain. Neither prevention nor even adequate treatment is possible within that isolated framework.
Not surprisingly, the common tendency to over-medicalize problems that are actually of a psychosocial nature is, therefore, all too often unsuccessful [Savić 1993]. Problems such as, for example, prolonged sickness absence, job-related exhaustion, low motivation for work tasks, or, on the other hand, excessive involvement in work with attendant anxiety and tension, often cannot be solved by the clinician and patient alone.
Yet, as will be amply illustrated in this book, the clinician, particularly the neuropsychiatrist, is in a key position to provide an interface between the patient and work environment.
1.1.1 Preventing and overcoming demoralization: a critical task
Numerous experts in the field, have placed the prevention of demoralization as one of the critical tasks of modern psychiatry [Connor & Walton, 2011] [Cherny, 2010] [Gabel, 2012] [Kissane, et al, 2010] [Perakis, 2010] [Sansone & Sansone, 2010]. This concern about demoralization as well as the stigma surrounding mental health is shared by Professor Norman Sartorius, former director of the World Health Organization Division of Mental Health, and former president of the World Psychiatric Association [Kissane et al, 2010]. Demoralization is characterized by a psychological state of fear, dysphoria, loss of self-confidence and self-respect, along with feelings of hopelessness, isolation, and the inability to face new situations. Demoralization can occur as a consequence of somatic disease or fear of disease, but it can also arise without any relation to real or imagined pathology. Countering and preventing demoralization is an essential component of the physician-patient relationship and the therapeutic process. In other words, helping the patient to regain self-confidence and self-respect, as well as to evoke feelings of hope and optimism, even under very difficult circumstances, are as vital, and sometimes even more so than the actual biomedical treatment.
Within the context of mental ill-health which has developed in relation to a stressful work environment, the starting point for recovery is to bring about some change in work conditions, sometimes even relatively small, that can help initiate a positive feedback loop. Thereby, the patient begins, typically with the aid of psychotherapy and sometimes also medication, to regain a sense of control over his or her working life, returning to productive and active engagement in job tasks. Returning to work, under healthier conditions, can thereby be viewed as an integral part of overcoming demoralization.
1.2 Insights from Cognitive Neuroscience
Defining these “healthier conditions” of work is within the domain of cognitive neuroscience, or more specifically, cognitive ergonomics, informed by brain research. Tremendous strides have made in our understanding of the human nervous system. This knowledge can be used to help create working conditions that are in harmony with human needs.
As stated in the Tokyo Declaration on Work-Related Stress and Health [Tokyo Declaration, 1998]:
“The growth of neuroscience and stress science has allowed elucidation of the links between social structures and processes (at work and outside it), the way in which these are perceived and appraised and the resulting interaction between the central nervous system and other organ systems to promote or counteract workers’ health, based on a bio-psycho-social approach to all relevant aspects of the [human] - environment ecosystem and its dynamics” (p. 2).
1.2.1 Work stressors vs. the stress response: a key distinction
One of the major stumbling blocks in this area has been the lack of distinction between the stressors, namely the objective characteristics of a given set of working conditions, and stress or how the individual perceives and responds to these stressors. We paraphrase the formulation of Professor Walter Rohmert [1971] as a helpful starting point for clarification. He clearly distinguishes the evaluation of work from the assessment of the individual worker, whom he terms the “human operator.” The independent factors of work are the stressors. These stressors can potentially elicit a stress response in a given individual. The physiological, psychological and social reactions of a given individual upon exposure to these stressors are the dependent variable. The nature of this stress response is related not only to stressors, but also to the characteristics of the given person. The various phases and physiological components of the stress response have been described in the seminal works of Cannon [1914] and of Selye [1976], as well as of Folkow [1988] Frankenhauser and Johansson [1986], Henry [1992], Kagan and Levi [1974] [Levi, 1972], Wolf [1995], inter alia.
The distinction between stressors and the stress response is of utmost importance, especially for occupations in which many of the most taxing stressors are not readily apparent. It is here, as we will demonstrate, that insights from cognitive neuroscience prove to be invaluable.
1.3 The Aims and Organization of this Book
We have chosen the title of this book to reflect our fundamental aim: to explore the relation between exposure to job stressors and mental health. This is done with the primary intention of developing a new clinical approach, one which takes a proactive stance, emphasizing the need for creating work conditions that are more in harmony with the needs of the human being. Pivotal to this endeavor is to provide an integrative and comprehensive methodology for assessing work stressors and ameliorating them whenever possible. This methodology, the Occupational Stressor Index, the OSI, is our own [Belkić 1989] [Belkić 2003] [Belkić & Savić, 2008]. We have successfully applied the OSI over the years in the context of prevention-oriented clinical practice within neurology and psychiatry, as well as within cardiology, oncology and other medical disciplines.
We the authors, as clinicians ourselves, have a special interest in and affinity with our colleagues, our fellow physicians [Savić 2002] [Belkić & Nedić, 2007]. This is motivated by a number of considerations that we will discuss in detail later on. At this juncture, suffice it to say that the working conditions and mental health of physicians will be strongly emphasized throughout the book.
We would also like to emphasize that gender considerations are woven into the entire book. Gender medicine is coming to be appreciated not only as a specialty in itself, but also an approach that is needed for all aspects of medicine. Gender is a key effect modifier that warrants consistent attention in research on the work environment and health [Belkić, Landsbergis et al., 2004] [Messing 2000] [Nedić, Belkić, et al, 2008a].
Part I of this book sets the stage. In Chapter 2, we first present the leading sociological models used to assess the work environment and then review the epidemiologic evidence concerning job stressors and psychosomatic health and ill-health, emphasizing mental health outcomes, as well as salient somatic co-morbidities. Included are considerations of various aspects of “work deprivation": unemployment, prolonged sick leave, job insecurity as well as retirement.
The evidence presented in Chapter 2 justifies proceeding further to examine the “econeurologic” mechanisms by which work stressors impact upon the central nervous system, the theme of Chapter 3. In order to do so, we needed to present some basic information about how the brain receives and handles information: the aversions and affinities of the human nervous system in relation to the environment. Illustrations are provided to facilitate this aim, and, hopefully, to spark interest and curiosity to delve further. This also represents a unified vantage point from which various types of stressors: mental, physical and ergonomic, can be considered in concert, with respect to their effect upon the central nervous system. Our methodological focus is electroencephalography in its various applications, in particular, event-related potentials. In the latter part of Chapter 3 neurophysiological processes are examined in direct relation to psychiatric and neurologic disorders. We segue to a review of the current standard of care concerning work fitness and occupational rehabilitation in Chapter 4. Again, the focus is upon mental health, but there is also much to be learned from return to work considerations for patients with cancer, cardiovascular disease and rheumatologic/ musculoskeletal disorders, inter alia. Since pulmonary medicine offers perhaps the most advanced approach to assessing work fitness, work- related respiratory disorders and occupational hygiene, albeit for physical- chemical rather than psychosocial/ergonomic exposures, we devote a portion (4.3.5) to that topic. Special considerations concerning work fitness and public safety are also discussed in Chapter 4.
Chapter 5 is devoted to a full presentation of the Occupational Stressor Index: its theoretical and physiological basis derived from cognitive ergonomics and brain research and also incorporating salient aspects the sociological models, the organization of the OSI as a two-dimensional matrix, the generic versus specific OSI instruments for physicians and certain other occupations. Its reliability and validity including empirical results among physicians and certain other occupations are also reviewed. The clinical validity of the OSI is discussed in the concluding section of Chapter 5 (5.4.4), thus leading us into Part II.
Part II of this book contains eight clinical case studies. The major diagnosis for nearly all of these patients is psychiatric or neurologic. The first and concluding case studies are of physicians, and the fourth clinical case is an oncology nurse who has been afflicted with breast cancer and suffers from sleep disturbances. The OSI is applied to each of the case studies, both for baseline assessment of the work environment and for formulating and implementing modifications. Chapter 6 provides a more detailed introduction to the clinical case studies.
In Part III a novel clinical approach to mental health is introduced, in which the work environment is the focus. On the basis of Parts I and II, we suggest that there is a need for new subspecialty: Occupational Neuropsychiatry. In Part III, we envision how this expertise could contribute to healthier, more humane work environmentsfor patients with mental health disorders, as well as more broadly for working populations.
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Part I – Background
Evidence, Mechanisms, Current Standard o...
