Occupational stress: Reections on theory and practice

Dianna T. Kenny
Chapter 20, (pp 375-396), Kenny, D. T., Carlson, J. G., McGuigan, F. J., & Sheppard, J. L. (Eds.) (2000). Stress and health: Research
and clinical applications (467 pages). Amsterdam, The Netherlands: Gordon Breach/Harwood Academic Publishers. ISBN 90 5702
376 8.

INTRODUCTION
Whether burdened by an overwhelming urry of
daily commitments or stied by a sense of social
isolation (or, oddly both); whether mired for hours
in a sense of lifes pointlessness or beset for days
by unresolved anxiety; whether deprived by long
work weeks from quality time with ones offspring
or drowning in quality time with them whatever
the source of stress, we at times get the feeling that
modern life isnt what we were designed for (Wright,
1995, p.62).

Occupational stress is currently one of the most

costly occupational health issues (Cooper & Cartwright, 1994; Cooper, Luikkonen & Cartwright,
1996; Cotton & Fisher, 1995; Karasek & Theorell,
1990; Kottage, 1992). The deleterious implications
for individuals and organisations are manifold, and
can result in serious physical and psychological illness for individuals, and major resource loss for organisations. The extent and progression of the problem over the past 20 years have been eloquently
documented elsewhere [see Levi (this volume); &
Spielberger, Reheiser, Reheiser, & Vagg (this volume)].
Occupational stress research has concentrated on
aetiology (Hart & Wearing, 1993; Toohey, 1993),
measurement (Spielberger, 1998), and tertiary interventions. These have focused on either enhancement
of the individuals coping capacity (Murphy, 1988)
or broader organisational level changes such as increased worker participation in decision making,
job enlargement and enrichment, redesign of jobs
and working environment, and creation of a more
supportive work environment through a range of
human resource management interventions (Cooper et al, 1996; Hart & Wearing, 1995; Levi, 1990).
As effective as some of these strategies are in large
scale restructuring enterprises, many organisations
are deterred from such global changes as a means of
preventing and managing occupational stress. This
is due to the cost and intrusion of such strategies and
the relatively small numbers of employees manifesting stress conditions that impair occupational
functioning at any one time in any one work place
Occupational Stress 16

(Cooper & Payne, 1992). There will always, therefore, be a need to cope with occupational stress on
both the macro (organisational, structural, political)
and micro (individual, dyadic, triadic) levels. This
paper contributes to the enhancement of managing
occupational stress at the micro level.
Firstly, a systemic model for understanding occupational stress is proposed. Some extant theories of
occupational stress will then be reviewed, and interventions arising from these theories are assessed.
Finally, an intervention for the rehabilitation of occupational stress based on the proposed model and
theoretical discussion is outlined.
THE MODEL
In a series of recent studies (Kenny, 1995a, 1995b,
1995c, 1995d, 1995e, 1995f, 1995g, 1996), Kenny
explored the causes of the failure of occupational
rehabilitation to effect a sustainable return to work
following workplace injury. She concluded that a
systemic framework provided both the most heuristic explanation for such failures and a workable
model on which to base subsequent rehabilitation
interventions. Accordingly, the model for both understanding occupational stress and to occupational
stress interventions, proposed in this chapter is informed by systemic theories, including cybernetics,
communication theory, family therapy as applied to
the systems (ie workplaces, organisations and workers compensation system) in which the worker is
located, and current theories of occupational stress
which embrace a systemic epistemology (Bowen,
1987; Cottone, 1991; Hart & Wearing, 1995; Karasek & Theorell, 1990; Kenny, 1995e).
A systemic theoretical model for tertiary rehabilitation of occupational stress (Cottone & Emener,
1990; Kenny, 1995g) is different to other models in
that the focus is on neither the individual, nor the
organisation, but on the system as a whole. In this
model, occupational stress is understood as the systems attempt to maintain equilibrium or to restore
homeostasis (Hart & Wearing, 1995; Hoffman,
Kenny D.T., 1999

1981). Occupational stress is not considered to be

symptomatic of intra psychic pathology of the identied client, as in the medical model, or a result of
environmental factors, as in the sociological model. In the proposed model, a circular epistemology
(Hoffman, 1981; Keeney, 1987) informs the rehabilitation process by conceptualising relationships and
processes within the system as the proper subject of
investigation and intervention, thereby illuminating
a range of intervention strategies at both the individual and organisational levels. Another important
feature of a systems theory framework that differs
from current approaches is the temporal location,
which is focused heuristically upon the present and
future, rather than on a forensic establishment of
fact based upon past actions and processes.
THEORIES OF OCCUPATIONAL STRESS
Psychological theories
The predominant paradigm for understanding
the causes of occupational injury and illness is the
medical model (Quinlan & Bohle, 1991; Quinlan &
Johnstone, 1993). With its emphasis on individuals
rather than groups, on treatment rather than prevention, and on technological intervention rather than
environmental change, the medical model has been
very inuential in controlling both the way in which
occupational injuries and illnesses have been dened and the means by which they are managed.
The major criticism of the medical model has been
its focus on treating sick or injured workers rather
than on producing healthy working environments
(Biggins, 1986). The outcome of this approach was
to perpetuate the notion that workplace injuries are
accidents which were not preventable and to locate the blame for the injury in the individual worker or in the hazardous nature of the work (Davis &
George, 1993; Ferguson, 1988; James, 1989).
The disciplines of industrial, occupational and
health psychology have not lived up to their early
promise because they have adopted a managerialist
orientation akin to the medical model. That is, they
tend to focus on the characteristics and behaviours
of individual workers and avoid addressing the role
that the structure of power and authority in industry play in occupational well-being (Bohle, 1993).
For example, although the relationship between
monotonous, deskilled and machine-paced work
and environmental and organisational factors such
as shiftwork, piece work, excessively high or low
work demands, and poor working conditions on
psychological and physiological stress responses
Chapter 20, Stress and Health

in workers have been demonstrated (Clegg & Wall,

1990), their impact is predominantly assessed in relation to individual attitudes and behaviour, rather
than in relation to the structure of workplaces and
the organisation of labour (Quinlan, 1988).
Sadly, the history of psychological theories of occupational stress, and indeed occupational injury
generally, has been one of nding victims to blame,
and then to intervene in a linear way to alter the performance of the latest scapegoat. Proponents of these
models have variously blamed the job, blamed the
equipment, blamed the worker, and blamed management (Cooper, 1995; Kenny, 1995e; Habeck, 1993;
Quinlan, 1988; Willis, 1994). Such theories have
spawned an enormous amount of research searching
for the putative factors responsible for occupational
stress. Personality and organisational factors have
been identied as the major culprits.
Personality has always been considered a major
mediator of stress reactivity. That is, although certain events are regarded as normatively stressful,
sensitivity to stressors varies between individuals.
That is, individuals with different personalities will
respond similarly to physical threats, but different
responses to ego threats are related to personality
differences (Eysenck, 1988). Most theories of occupational functioning agree that personality makes
a signicant contribution to performance and wellbeing, while acknowledging that the relationship
between personality and environmental factors is
dynamic and complex. For example, Work Adjustment Theory (Rounds, Dawis, & Lofquist, 1987) is
founded on the notion that stable cognitive, behavioural and emotional dispositions underpin work
adjustment, but that situational inuences impact
upon these stable dispositions for adaptation and
change, in both positive and negative ways. Similarly, Headey & Wearing (1992) found that enduring personality characteristics, such as neuroticism
and extraversion, determine peoples daily work
experiences, use of coping strategies, and levels of
psychological distress and well-being. Extraversion
has been positively correlated with subjective wellbeing (Costa & McRae, 1980), while introversion
and neuroticism are associated with increased stress
(Fontana & Abouserie, 1993), emotional exhaustion
and depersonalisation (Piedmont, 1993).
Hobfoll (1994), reacting to what he perceives to
be the current over-emphasis on environmental factors, has urged a re-consideration of the role of personality in the aetiology of occupational stress. He
states that we can Ano longer pretend that there is an
objective way to dene stress at the level of environOccupational Stress 17

mental conditions without reference to the character of the person@ (p 24). In similar vein, Roskies,
Louis-Guerin, & Fournier, (1993) concluded that
personality can cushion as well as aggravate the
impact of occupational stress (p. 616-7); with negative personality dispositions transforming stressors
into strains and strains into symptoms. Negative affectivity, for example, has been associated with interpersonal conict (Spector & OConnell (1994),
negative emotions (Chen & Spector (1991), psychological distress, physical symptoms (Watson, Pennebaker, & Folger, 1986), and job strain (Decker &
Borgen, 1993). The relationship between role stress
and role distress has been found to be moderated
by a range of personality characteristics including intolerance of ambiguity, dependency, strong
afliation needs, low risk propensity (Siegall &
Cummings (1995), and high self-focused attention
(Frone, Russell, & Cooper, 1991). On the positive
side, humour and optimism can signicantly moderate the relationship between daily hassles, self-esteem maintenance, emotional exhaustion and physical illness (Fry, 1995).
Despite the enthusiasm for the view that personality characteristics are fundamental to an understanding of occupational stress, empirical support
for such moderating effects has been mixed (Frone
& McFarlin, 1989). Moreover, much of the research
has been atheoretical or exploratory, and it is difcult to formulate interventions based on ndings
that a small amount of variance in the experience
of occupational stress is accounted for by a particular personality characteristic. Researchers working
within this framework would, of course, recommend that interventions be aimed at increasing humour, optimism and tolerance of ambiguity and decreasing negative trait affectivity, neuroticism and
dependency. However, the literature is replete with
evidence that personality characteristics are notoriously difcult to modify (McRae & Costa, 1994).
Even if it were possible to change personality in the
desired direction, it is not certain that workplace
difculties would improve without simultaneously
attending to extrinsic organisational factors that
may be operating. Moreover, personality traits may
be xed to some extent, but their place in the system as antecedents or consequences will depend
on the nature of the interaction between individual
and environmental systems, and to any changes that
may occur within that system. Personality may also
be dened as a function of coping style (Eysenck,
1988); consistent with a systemic framework, coping behaviours will also be inuenced by the sources
of occupational stress (O=Driscoll & Cooper, 1994)
Occupational Stress 18

and the resources and external support available for

dealing with them (Hart & Wearing, 1995).
Research into the role of organisational factors in
the aetiology of occupational stress has followed a
similar trajectory to the one outlined above for personality. Ever lengthening lists of putative factors
have been identied. In two reviews of occupational
stress, Cooper (1983; 1985) summarised and categorised six groups of organisational variables, outlined below, that may cause stress in the workplace.
These are
1. Factors intrinsic to the job (eg heat, noise,
chemical fumes, shiftwork)
2. Relationships at work (eg conict with coworkers or supervisors, lack of social support)
3. Role in the organisation (eg role ambiguity)
4. Career development (eg lack of status, lack of
prospects for promotion, lack of a career path,
job insecurity)
5. Organisational structure and climate (eg lack
of autonomy, lack of opportunity to participate
in decision making, lack of control over the
pace of work)
6. Home and work interface (eg conict between
domestic and work roles; lack of spousal support for remaining in the workforce).
There is, of course, a complex relationship between occupational and organisational factors and
psychological characteristics. Interpersonal conict
in the workplace, increasingly recognised as a major
contributor to work disability, has a complex aetiology. Dissatisfaction with life, daily stress, neuroticism and hostility were all found to be signicant
risk factors for interpersonal conicts at work for
both men and women (Appelberg, Romanov, Honkasalo, & Kosdenvuo, 1991)
Responses arising from a psychological framework have focused on tertiary and secondary interventions. Tertiary interventions include individual
counselling, stress management programs, employee assistance programs, and workplace mediation
for conict resolution (Appelberg, Romanov, Heikkila, Honkasalo, & Kosdenvuo, 1996). Secondary interventions include training and education
(Mackay & Cooper, 1987; Bohle, 1993). This is not
to say that such interventions are never effective in
reducing occupational stress. In a recent study, Reynolds (1997) reported that individual counselling
improved psychological well-being while organisational level interventions (ie increasing employees
participation and control) did not. However, Bohle
Kenny D.T., 1999

(1993) argued that, in general,

Interventions of this nature imply that the problem of stress lies primarily with the individual,
that the responsibility for change consequently lies
primarily with workers, and that organisations are
only responsible for assisting individual workers
to change. since no attempt is made to reduce or
remove environmental stressors, interventions can
best be seen as attempts to increase workers tolerance of noxious and stressful organisational, task
and role characteristics (p.111).
While advancing our understanding to some degree, both personality and organisational factors research has remained wedded to the dominant medical and psychomedical paradigms outlined above.
Although they highlight important putative factors
that may contribute to occupational stress, these
factors, considered separately, do not inform the rehabilitation process. Let us now turn to other models and approaches that may assist in this regard.
Sociological theories
The most radical departure from the medical
model has been the approach of industrial sociologists who have brought the social organisation of
work as the primary determinant of occupational
injury, illness, and stress into sharp focus (Berger,
1993; James, 1989; Williams & Thorpe, 1992). The
medical models notion of health and illness is rejected as reductionist, individualistic and interventionist, in which subjects are considered as unique
cases, independent of cultural, social, political, and
economic structures and processes. Industrial sociologists argue that power structures, the institutionalised conicts of interest between safety and productivity, the social division of labour, the labour
process, industrial relations and politics are the root
causes of occupational illness and stress (McIntyre,
1998; Peterson, 1994).
Recent changes to legislation in occupational
health and safety and workers compensation have
shifted the perception of occupational health from
an individual and marginalised process to a process with major economic and political implications
(Kenny, 1994a; 1994b; Willis, 1989). These changes have led to the revised view that occupational illness is a social process, the dimensions of which are
not individualised, unique or specic. Further, sociologists argue that for every occupational illness or
injury, there are physiological and ergonomic components whose effects are mediated by the social
environment, specically, the organisation of work
and the sociology of medical knowledge surroundChapter 20, Stress and Health

ing the illness or injury (Figlio, 1982). Negotiation

over the social and political meaning of occupational illnesses and their various economic and social
implications occurs prior to their being awarded the
status of a syndrome (Willis, 1994). The irony of
such a process is that while gaining recognition that
such conditions are public issues, solutions continue
to be sought in the individual. With some notable
exceptions (Levi, 1998), this has been the case for
occupational stress.
The major contribution of sociological approaches
to occupational illness is that occupational health
and safety has increasingly become an industrial
relations issue between capital and labour;it has
increasingly come to mediate the social relations of
production (Willis, 1994, p.138). In other words,
the focus has shifted from a fatalistic acceptance
that there will be casualties of the work process to a
legislated requirement that employers provide a safe
workplace for all employees. The cost of compensation is increasingly shaping occupational health
and safety practices and procedures and hence the
labour process itself (McIntyre, 1998).
Negotiating safety in reference to occupational
stress is, of course, more difcult than negotiating
safety with respect to the physical hazards of the
workplace. Occupational stress currently occupies
a similar nebulous position in the medical nomenclature that RSI (Repetitive Strain Injury) occupied
in the last decade. One must demonstrate that the
incidence of illness (presence of symptoms) is connected to the organisation of work, and as stress is a
transactional process involving interactions between
physiological, psychological, behavioural and organisational variables, demonstrating the causal
nexus is not an easy matter. Moreover, the legislated
requirements may in fact have worked against the
resolution of issues related to occupational stress,
requiring as they do the certication of a specic
illness on the Workers Compensation certicate.
Legitimating the experience of occupational stress
medically may militate against an organisational or
transactional solution to the problem, since certication, a process achieved through political action,
has individualised the problem and returned full circle to the victim blaming approach of the medical
model.
Systemic theories
In advocating a systemic/transactional approach
to occupational stress, it needs to be stated that there
are circumstances in which either personality is so
damaged or environmental conditions are so adverse, that the relational context of one to the other
Occupational Stress 19

is irrelevant. These special cases must be dealt with

on a case-by-case basis requiring unique solutions,
ranging from the individual to the political.
Several theories of occupational stress that utilise
social systems theory have been developed (Bacharach, 1991; Edwards, 1992; Furnham & Schaeffer,
1984; Frone & McFurlin, 1989; Hart & Wearing
(1995); Hobfoll, 1989; Karasek, 1979; Karasek &
Theorell, 1990; Lazarus & Folkman, 1984; McGrath 1976). Space permits only a brief summary of
the relevant models here, and the interested reader
is referred to the many excellent reviews available
for a comprehensive coverage.
Person-Environment Fit Theories
Person-Environment (P-E) Fit theories (Caplan &
Harrison, 1993; Furnham & Schaeffer, 1984) were
early precursors to the dynamic systemic theories
described in the next section. Caplan (1987) used
P-E t theory as a method for understanding the
process of adjustment between employees and their
work environment. According to this framework,
occupational stress is dened in terms of work characteristics that create distress for the individual due
to a lack of t between the individual=s abilities and
attributes and the demands of the workplace. Caplan
(1987) suggested that recollections of past, present,
and anticipated P-E t might inuence well being as
well as performance.
Interventions are directed at measuring t prior
to vocational placement, or measuring discrepancy
in t in the identication of occupational stress aetiology. Interactions between person (eg personality traits, vocational orientation, and experience)
and environment variables have been found to be
better predictors of strain than either person or environmental variables considered separately (Antonovsky, 1987a; Caplan, Cobb, & French, 1975).
However, characteristics of jobs and characteristics
of workers may inuence each other in dynamic reciprocal ways. Most P-E t theories are static and
failed to address the ongoing, reciprocal inuences of environment and person (Kulik, Oldham, &
Hackman, 1987).
Demand-Control theories
A development and expansion of job strain models, the demand-control model (Karasek, 1979)
concerns the joint effects of job demands and job
control on worker well being. Demand is subdivided into workload, work hazards, physical and emotional demands and role conict. Control relates
to substantive complexity of work, administrative
Occupational Stress 20

control, control of outcomes, skill discretion, supervision, decision authority and ideological control
(Muntaner & Schoenbach, 1994; Soderfeldt, Soderfeldt, Munstnaer, OCampo, Warg & Ohlson, 1996).
Based on the dimensions of demand and control,
jobs have been classied into four categories. These
are high strain jobs (high demand/low control); low
strain jobs (low demands/high control); active jobs
(high demands/high control); and passive jobs (low
demands/low control) (Landsbergis, Schnall, Dietz,
Friedman, & Pickering, 1992). In general, psychological distress is predicted by high demand/low
control combinations (Karasek, 1990). Conversely,
an increase in control is positively correlated with
job satisfaction (Murphy 1988). Control has also
been implicated in occupational stress arising from
organisational change processes, where control is
conceptualised as a stress antidote (Sutton & Kahn,
1986). The perception of control can also be linked
to personality factors, such as locus of control and
private self-consciousness (Frone & McFarlin,
1989; Kivimaki & Lindstrom, 1995).
Johnson and Hall (1988) have expanded the model to include a support component incorporating
coworker and supervisor social support. Social support has positive effects on well-being and buffers
the impact of occupational stressors on psychological distress (Karasek, Triantis, & Chaudry, 1982).
Low social support has been associated with greater
symptomatology, and a signicant interaction with
demand and control has been observed for job dissatisfaction (Landsbergis, Schnall, Dietz, Friedman,
& Pickering, 1992).
Communication theory
Karasek and Theorell (1990) view occupational stress as a strategic communication of distress.
Toohey, (1993, 1995) has expanded this concept into
a model of functional communication. In this model,
dissatisfaction at the workplace may be expressed
through illness behaviour (ie occupational stress),
which is assessed as a safe and acceptable manner
in which to communicate distress (Toohey, 1995,
p 57). It is certainly debatable as to how expressing
ones distress in this way is either safe or acceptable
in a workplace context, especially given the social
stigma attached to both mental illness, and to workers compensation claims generally. However, these
methods are obviously more acceptable than outbursts of anger, physical violence or criminal acts
such as theft or destruction of property. This model
is just a step away from the systemic analysis of the
function of the symptom in the system in which it
occurs (Hoffman, 1981; Palazzoli et al., 1986), to
Kenny D.T., 1999

which we will shortly turn our attention.

Dynamic equilibrium theory
A recent innovative approach to understanding occupational stress has been proposed by Hart, Wearing, & Heady, 1993c; Hart & Wearing, 1995; Headey & Wearing, 1992). They challenge the prevailing
Cannon (1929) Selye (1975) view of stress which is
based on an engineering model where stress is understood as the force exerted on a structure, which
may then show signs of strain in response to that
force. The missing part of this formulation are those
characteristics which create susceptibility to strain,
either through innate personality traits, behaviours,
resources, or organisational factors. According to
the dynamic equilibrium theory, stress is not dened
as a demand, a response or a process, but as a state
of disequilibrium that arises when a change occurs
that affects the individuals normal levels of psychological distress and well-being. To understand
the cause of this change, it is necessary to separately
assess the impact of personality, organisation, coping processes and both positive and negative work
experiences. People may respond with both positive
and negative affect to the same environment (Diener & Emmons, 1985), and psychological well-being is therefore determined by the balance between
separate positive (eg extraversion, salutogenic life
events) and negative (eg neuroticism, adverse life
events) factors (Bradburn, 1969), each one of which
has its own unique set of causes and consequences
(Hart, 1994). Hart and Wearing (1995) argue that
both stable personality characteristics and the dynamic interplay between coping and daily work experiences together account for changes in levels of
psychological distress and well-being.
Although often used interchangeably in the occupational stress literature, Hart and Wearing (1995)
have demonstrated that psychological distress and
morale operate as separate dimensions and make
independent contributions to the quality of work
life. That is, positive work experiences impact upon
morale, and negative work experiences impact upon
psychological distress. This suggests that morale
may be improved by increasing positive work experiences and that psychological distress can be reduced by decreasing negative work experiences. In
addition, research with teachers and police ofcers
has indicated that these professional groups are not
stressed so much by the nature of their work, but by
the organisational context in which the work occurs
(Headey & Wearing, 1992). The implication of this
nding is that intervention should focus on developing a supportive organisational climate that enables
Chapter 20, Stress and Health

workers to cope more adaptively with operational

work demands, rather than to direct change efforts
at the nature of the work per se. A core set of organisational factors, among them staff relationships and
leadership quality, is related to both psychological
distress and morale. Other factors, such as excessive
work demands, are negative and relate only to psychological distress, while factors such as opportunities for advancement, are positive and relate only to
morale (Hart, Conn, Carter, & Wearing, 1993). That
is, strain occurs when excess elements (eg demands)
may threaten one need and decit elements (eg lack
of communication or support) may threaten another.
Careful analysis of both positive and negative organisational characteristics is therefore needed before intervening to ameliorate identied problems.
Cybernetics and Systems Theory
Cybernetics and General Systems Theory were
developed concurrently and are based on similar
theoretical principles. Social systems theory emphasises wholeness, the interaction of component parts,
and organisation as unifying principles (Goldenberg
& Goldenberg, 1985, p28); incorporates non-linear
theories of causation (Cottone 1991); and is based
upon a circular epistemology (Hoffman, 1981).
Cybernetics has been dened as a science of
communication and control in man and machine
(Edwards 1992; Frone & McFarlin, 1989; Weiner,
1948); an epistemological foundation for personal
and social change (Bateson 1972), which focuses on
mental process (Keeney, 1983), whereby individuals monitor their psychological and physiological
reactions to various stressors@ (Frone & McFarlin,
1989, p876). In cybernetic theory, the concept of
feedback is the pivotal process. Feedback describes
a process whereby the system initiates homeostatic mechanisms based upon information received.
Hoffman (1981) describes feedback loops as either
deviation amplifying or deviation counteracting,
whereby a system either stabilises, moving to a state
of equilibrium, or destabilises, moving to a state of
disequilibrium. According to a cybernetic analysis,
systems or organisations may undergo rst or second order change. In rst order change, negative
feedback is the process whereby systems maintain
their organisation through deviation-counteracting
mechanisms such as homeostasis, morphostasis,
and self-correction (Sluzki, 1985). In second order
change, positive feedback loops amplify deviation
(ie create change rather than maintain stasis).
Feedback loops are initiated when an individual
identies a discrepancy between a perceived current
state that creates imbalance and discomfort, and anOccupational Stress 21

other desired psychological and/or physiological

state (Frone & McFarlin, 1989). The individual then
assigns signicance (importance) to the discrepancy (Carver & Scheier, 1981; Cummings & Cooper,
1979; Edwards, 1992). The importance or meaning accorded this discrepancy determines whether
a feedback mechanism is initiated (Edwards 1992).
In an interesting variation of this theme, Buunk and
Ybema (1997) have proposed that experiencing occupational stress, or any form of uncertainty, instigates a desire for social comparison information,
that is, a need to discover how other people feel
about the situation. Contact with similar others may
lead the individual to adapt his/her stress response
to those of other group members. Such a process
may account, in part, for particular patterns of occurrence of occupational stress or illness that have
been identied (Willis, 1994).
Consistent with circular causality and the mutability of causal direction in relation to key variables,
coping is dened as discrepancy reduction behaviour (Frone & McFarlin, 1989); an outcome of the
stress process (Edwards, 1992), as a component of
the intrapersonal variables which make up personality, which inuence both the initial susceptibility to
perceived stressors (variables such as ego strength,
hardiness etc) and the ability to respond to the threat
to homeostasis in systemic terms (or the discrepancy occurring between perceived and desired states
in cybernetic theory). The application of a circular
epistemology resolves current disagreement over the
function and consequences of coping as either a mediator of the stress-strain relationship or as a moderator (stress buffer) of the relationship (ODriscoll
& Cooper, 1994). Edwards (1992) describes stress
explicitly as a discrepancy between perceptions and
desires, rather than a conict between demands and
abilities, as in Selyes model (Selye, 1975), which
Edwards views as predictors of coping efcacy,
rather than stress per se (p 246).
Although the parallel is rarely drawn, there is a
strong philosophical relationship between the concept of discrepancy in systems theory, alienation
in Marxs theory of the pathology of social change
(Marx, 1982), and Durkheims (1952) anomie. Susan Sontag (1978) conceived of illness as metaphor
within sociological theorising at about the same
time that psychologists and family therapists were
embracing the notion of the symptom in the identied patient as a metaphor of family dysfunction
(Bowen, 1978; Haley, 1964; Minuchin, 1974; Palazzoli, 1986). Similar analogies have been offered
subsequently, for example, Williss (1994) analysis
of RSI as a metaphor for alienation. Applying these
Occupational Stress 22

concepts to occupational stress, one could argue

that occupational stress arises when, through either
individual or organisational change processes, a discrepancy occurs between the personal values of the
worker and the values of the organisation to which
s/he belongs. Because managers and supervisors
are key representatives of organisational culture, it
is most often within the relationship between the individual and the supervisor that the individual will
experience alienation (McIntyre, 1998).
The experience of occupational stress and its
concrete manifestation ie the lodging of a workers
compensation claim, is the functional communication of distress brought about by alienation (Karasek & Theorell, 1990). In Edwards (1992) theory,
alienation may be understood in terms of thwarted
desires, which produce negative emotions such as
anger, disillusionment, or the desire for retribution
or revenge. Decreased worker morale, in dynamic
equilibrium theory (Hart & Wearing, 1995), may be
conceptualised as a precursor to alienation if steps
are not taken to remedy the morale problem early in
the cycle. Similarly, Kenny (1995c; 1995d) argued
that the failure of some injured workers to return to
work following workplace injury was due, at least
in part, to a failure of management to either believe
that the injury was genuine or to show care, concern
and respect to the injured worker. These failures set
up a negative feedback loop in which workers experienced a narcissistic injury that resulted in anger,
hostility, and a desire for revenge against management, which of course, leads to alienation between
worker and management.
REHABILITATION OF
OCCUPATIONAL STRESS
Occupational rehabilitation theories have followed
the dominant paradigms of occupational stress and
can be summarised using four broad categories.
These are a) expert technical approaches that focus on the physical environment of work and work
practices; b) work psychology, which attributes illness to worker behavioural characteristics as well
as to some immediate organisation behaviours such
as pay systems, supervising environments, etc.; c)
pseudo-psychology, a victim-blaming approach
which focuses on individual worker behaviour such
as malingering and accident proneness, and leads
to relatively inexpensive employer corrective activities such as pre-employment health assessments,
worker education, and drug tests; and d) sociological approaches which focus on broader social issues
such as power structures, prot/production imperaKenny D.T., 1999

tives and gender, ethnic and class divisions as well

as organisational behaviour (Johnstone & Quinlan,
1993).
The expert technical approach has improved the
ergonomic environment of workers, but on its own,
cannot account for all problems related to occupational injury or occupational stress. Willis (1994),
for example, questioned why some workers developed RSI after years of using the same equipment,
or continued to develop RSI after ergonomic furniture, pause strategies and exercises, and work redesign had been introduced into the workplace. The
work psychology and pseudo-psychology models
are still generally based upon a medical model of
linear causality, which has hitherto provided the
dominant paradigm in tertiary rehabilitation (Cottone & Emener, 1990; Kenny, 1995c). Its basic requirement is the attachment of a medical or psychological diagnostic label to the claimant. In so doing,
the intervention becomes focused upon only one
component of a complex system (Toohey 1993),
namely the putative psychopathology of the individual. This approach militates against a successful
rehabilitation outcome, leading as it does, to victim
blaming (Davis & George, 1993; Kenny, 1995e).
Conversely, the political/advocacy approach, based
on a sociological analysis, attempts to resolve the
environmental issues to the exclusion of intra-psychic problems.
The ecological view of humans as living systems
dependent upon a healthy relationship with the environment is one of some currency in political, public
health and philosophical realms. The development
of this perspective into a model for explicating the
antecedent processes of occupational stress based
on cybernetics and systems theory has been foreshadowed, but not yet realised (Cottone & Emener
1990; Cox, 1987; Edwards 1992; Hart & Wearing
1995; Kenny 1995e; Tate, 1992). The ecological
view of occupational stress is succinctly summarised, as follows:
Work related psychosocial stressors originate in
social structures and processes, affect the human organism through psychological processes, and inuence health through four types of closely interrelated mechanisms emotional, cognitive, behavioural
and physiological. Situational (eg social support)
and individual factors (eg personality, coping repertoire) modify the health outcome. The work-environment-stress-health system is a dynamic one with
many feedback loopsthe approach (to intervention) should be systems-oriented, interdisciplinary,
problem-solving oriented, health (not disease) oriChapter 20, Stress and Health

ented, and participative (Levi, 1990, p1142).

Extant theories of occupational stress focusing on
cybernetics go some way towards operationalising
the concepts and exploring aspects of the model, but
not in relation to the design of interventions from
either a preventive or management perspective (Edwards, 1992; Frone & McFarlin, 1989).
The processes involved in occupational rehabilitation can be conceptualised cybernetically, in terms
similar to those of systemic family therapy. Bowen
(1966, 1978) was a systemic family therapist who
postulated the importance of the role played by triangles in family interaction. This process, called triangulation, occurs in all social groups, as twosomes
form to the exclusion of, or against a third party. Bowen proposed that a two-person system may form a
three-person system under stress. For instance, tension might arise between the two and the one who
feels most uncomfortable or vulnerable may triangle in a third party, to relieve tension and to restore
the power balance. The third party, once drawn in,
may form his/her own set of alliances, thus creating
shifting power balances. The action may not remain
localised within the original triangle, as more and
more stakeholders become involved in the ongoing
struggle. Bowen associates pathology with rigidity
and suggests that, although all systems create triadic
patterns, these patterns will become more rigid during periods of crisis or stress. The rigidity of the response patterns set up by injury/occupational stress
and the central players initial response to the claim
follow a limited and predictable path and set up a
highly restricted set of choices for the stakeholders
involved.
When a worker is injured/stressed, the matter is
initially dealt with in the injured worker-employer
dyad. If the worker and employer deal with the matter to their mutual satisfaction, no other parties need
become involved, other than in a service provision
capacity. That is the employer will notify the insurer, who will organise payment, and the injured
worker may contact a health professional for treatment. However, if the employer is dissatised with
the injured workers response to his injury (eg by
taking too much time off work, or by remaining on
shortened hours of work), he may call in the insurer,
not as a service provider, but as an ally against the
injured worker. The insurer will respond by disputing the claim for workers compensation, ordering
expert medical opinion and instructing the worker
to attend a doctor appointed by the insurance company. The injured worker may respond by attending
his own doctor, no longer only as a service provider,
Occupational Stress 23

but also as an ally who will assist the injured worker

to restore the power balance by organising medical specialist opinion which is frequently contrary
to the insurance doctors opinion. The parties may
then become polarised in an apparently unresolvable dilemma. One of the reasons for this is that the
issue of how best to manage the injury is replaced
with the issue of stakeholder integrity, particularly
that of the injured worker. The genuineness of the
injury becomes the focus of stakeholder involvement, rather than searching for the best social t
for the worker and his/her employer. The more parties who become involved, the poorer the communication between them and the greater the suspicion
and hostility. Recourse to the legal profession with
protracted legal proceedings is often the next step in
this process of triangulation.
Systemic concepts such as Bowens notion of
triangulation (Bowen, 1966, 1978), and Karaseks
notion of stress as a form of strategic or functional
communication (Karasek & Theorell, 1990), have
the capacity to provide a rm underpinning to the
model of tertiary rehabilitation described in this
chapter.
The proposed systemic model is particularly relevant to the analysis and case management of occupational stress. It suggests that the intervention of
the rehabilitation case manager should be directed
at identifying the dyadic and triadic relationships
and at providing clients with a functional means
of communicating their distress. It is vital that this
process allows the real sources of stress to be identied. In an interesting and provocative paper, Mahony (1996), building on Goffmans (1971) distinction
between front stage and back stage explanations of behaviour, argues that certain occupational
groups present front stage explanations only for
the causes of their occupational stress. Front stage
refers to those explanations that are most likely to
have currency with prevailing social norms, management, and in the case of claims for occupational
stress, the Workers Compensation authorities. She
sights the example of prison ofcers, whose front
stage explanations for occupational stress included
daily exposure to personal risk, resulting in safety
fears, including fears of injury and death at the
hands of violent criminals. The back stage reality,
that were the underlying causes of absenteeism, sick
leave and occupational stress was the inherent boredom of the job (eg standing in a tower on guard for
eight hours) and stigmatisation by outsiders. These
putative back stage factors would receive much less
support from management or Workers Compensation authorities. Therefore, workers may collude in
Occupational Stress 24

propagating the front stage reality to the detriment

of developing appropriate interventions for change.
Careful analysis is required to avoid intervening on
the basis of front stage interpretations of the problem. This may lead to impasses, stalemates, anger,
hostility, and industrial action.
Provision of the opportunity to deal with both
front stage and back stage issues, that may include,
among others, medical or treatment issues, industrial and legal issues, change management problems,
family problems, life cycle issues, underlying or
consequent psychological or psychiatric conditions,
and competence and training difculties, is a necessary component in the rehabilitation process. If successful, this communication will free both the client
and signicant stakeholders from the aggregation of
issues (eg searching for truth or blame and appointing scapegoats) that has resulted in triangulation
processes (see Kenny, 1995b, 1995e) that were both
precursors to the claim and impediments to successful return to work. This analysis also serves to clarify expected outcomes of the rehabilitation process,
as distinct from other (eg industrial/legal) processes
which may have a bearing on the resolution of the
problems (Nowland, 1997).
Due to the complex nature of the rehabilitation
process and the large number of stakeholders involved, the role of the case manager is central and
pivotal (Kenny, 1995c; Weil & Karls, 1985). The
adoption by the rehabilitation professional of an advocacy or adversarial role, either on behalf of the
worker, or on behalf of one of the other stakeholders
(usually the employer) may create a major barrier
to successful rehabilitation (Kenny, 1995a, 1995f;
Shrey, 1993). A systemically based intervention
will resolve these errors by clarifying the role of
the case manager within this system as an advocate
for the rehabilitation process, rather than for any of
the stakeholders. A systems framework emphasises
the importance of professional neutrality, providing
clear roles and functions based upon the professionals relationship to the system as a whole, rather than
to any one component (Furlong & Young, 1996).
This approach also serves to clarify expected outcomes of the rehabilitation process, as distinct from
other (eg industrial/legal) processes that may have a
bearing on the resolution of the problems.
The focus of the systemic intervention is the relationship between the injured worker and the system rather than an exploration of the individuals
traits, skills and capacities in isolation. It is based
on the cybernetic model outlined above which has
in turn been informed by the theories and processes
Kenny D.T., 1999

described in the preceding sections. In this model,

developed by Nowland (1997), and enlarged upon
here, the case manager should
1)
Map the stakeholders and their inter-relationships. Both the client and the case manager
need to understand who is involved, either overtly
or covertly. A eld map is then constructed of the
overall system of stakeholders and their relationships to one another in the system. Figure 1 presents
a prototypical example of a eld map. This map includes all most stakeholders who may become involved once a claim for workers compensation is
made. Not all clients will come into contact with all
parties outlined in Figure 1. However, the schematic
representation of the eld brings into sharp focus all
the possible dyadic and triadic relationships that can
occur in the post-injury period.

(Moos, 1987). In addition, the relationship of the

worker to his/her work in terms of demand/control/
social support may further illuminate the putative
sources of stress currently experienced. It may also
be possible to identify the dominant source of stress
within one of the identied sub-systems.
3)
Identify the rules governing the operation
of the sub-systems. The rules governing the behaviour of the sub-systems may not be consistent with
the purpose of the overall system, nor to be in the
best interest of successful rehabilitation. The case
manager needs to identify any homeostatic mechanisms that would operate to threaten change, and to
make these rules and mechanisms explicit.
4)
Identify the issues for the client. This step
assists the client to understand the systemic causal
relationship between his/her stress response and in-

Fig.1 A model of the proximal and distal stakeholders in the post-injury period and communication pathways

WCA

RP
Legend

RC

ID

InI

IW
TD
SG
S

2)
Identify sub-systems. Sub-systems are
identied by the commonality of their purpose and
rules. Different stakeholders may belong to more
than one sub-system, and through a process of identifying sub-system membership, conicts of interest
and alliances and coalitions may be claried (ie Bowens triangulation processes). The client is inevitably a member of a large number of sub-systems
simultaneously (ie workplace, medical and rehabilitation systems, family systems and social systems).
It is important to determine the relative strength and
inuence of each of these systems. The more intensive, committed, and socially integrated a setting,
the greater is its potential impact on the outcome
Chapter 20, Stress and Health

WCA

Work Cover Authority

RP

Rehabilitation Provider

Employer

Insurer

IW

Injured Worker

TD

Treating Doctor

ID

Insurance Doctor

InI

Insurance Investigator

SG

Support Groups

Solicitor

RC

Rehabilitation Coordinator

dividual and systems variables. This process will

highlight the initial factors as well as to identify
potential barriers to resolution of the problem. A
number of structured exercises can facilitate this
process (Brassard & Ritter, 1994). During this
stage, it is important that the case manager obtain
a clear understanding of the back stage issues for
the client, and to allow ample opportunity for the
functional communication of distress that may constitute one of the underlying impediments to the resolution of the issues. Clarifying and separating both
positive and negative work experiences may assist
the client to gain some conceptual clarication of
the causes of their psychological distress, as distinct
Occupational Stress 25

from vocational dissatisfaction or morale. This step

can then lead into stage 5 of the process.
5)
Apportion responsibility for management of
the factors. Different issues may need to be referred
to different personnel, either within or outside the
organisation. Possible sources of additional support
include union representative or other employee advocate, individual counsellor, or line manager. The
rehabilitation case manager co-ordinates and monitors these referrals and acts as a conduit and liaison
between the client and other stakeholders.
6)
Plan and implement the rehabilitation intervention. Once the aggregation of issues has been
dealt with, the case manager can then prepare the
client for return to work. During this phase, the case
manager gradually relinquishes responsibility to the
client and other key stakeholders in the workplace.
Preliminary investigation indicates that systemic
interventions have not previously been operationalised in this way and diverge in signicant ways from
current practice. Predictions from the application of
this model include role clarication for all stakeholders, case manager neutrality, task assignment,
increased ability to manage the multivariate factors
involved in a claim for occupational stress, challenging homeostatic mechanisms, and illuminating
a greater range of intervention strategies through the
systemic analysis of the precipitating and maintaining factors.
DIRECTIONS FOR FUTURE RESEARCH
This model for rehabilitation of occupational
stress is yet to be tested empirically. Model specication and implementation would be enhanced by
the following:
i) improving identication, nomenclature and
classication of occupational stress claims and separating them from related factors such as morale,
vocational satisfaction and attitudes towards work
(Hart & Wearing, 1995).
ii) development of strategies to avoid the medicalisation, and otherwise inadequate clinical management, of occupational stress claims. Current
problems are due to omver-medicalisation of occupational stress (Quinlan, 1988), poor diagnostic
skills in general practitioners (Kenny, 1996), poor
clinical assessment practices, passive clinical management from rehabilitation providers and over-reliance on claimant self-report as the principal source
of data (Cotton, 1996).
iii) an assessment of pre-program (eg availability
of Employee Assistance Programs, grievance proOccupational Stress 26

cedures, mediation services) and program (eg type

of intervention, by whom, stakeholders involved,
nature and frequency of contact) variables, which
can be linked to successful outcomes in the management of occupational stress claims. Although
there has been some recent attention to the development of stricter procedures, protocols, and role
specication of the various stakeholders involved in
the management of stress claims, the intervention
processes that occur at the different stages of the
life of the claim, and which contribute to successful/unsuccessful outcome have not, to date, been
sufciently elucidated
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