Stress

Professor John Grange looks at stress at work, described recently as "a serious health hazard reaching epidemic proportions", and considers how Christians might respond to it.


This article was first published in the Spring 2000 issue of Chrism. The author's profile below is from the same date

John Grange is a clinical microbiologist with a special interest in chronic infectious diseases, notably tuberculosis. In recent years his interest has turned from laboratory studies to global issues of disease control and he is currently involved in interdisciplinary issues. In addition, he has taken a keen interest in the Christian healing ministry and has contributed to various Christian journals including 'Contact' - the health and community development journal of the World Council of Churches.

© Guild of St Raphael

A Major Epidemic

Come unto me, all you that labour and are heavy laden, and I will give you rest (Matthew 11:28). As these words were spoken by Jesus, Christians should regard them as carrying a very deep meaning for society today as well as to those to whom they were spoken two millennia ago. It is appropriate and timely to consider this promise of rest for those heavily burdened by their labours in relation to what a Government Agency, the Health and Safety Executive, has recently stated is becoming a 'serious health hazard which is reaching epidemic proportions and is affecting the physical and mental health of as many as one in four employees' - namely, stress and anxiety as a result of pressure in the workplace1.

Indeed, stress has become quite a buzz word in recent years. One can hardly open a serious newspaper such as the Guardian without seeing accounts of how stressful modern living has become, and stress management is certainly a growth industry. It is noteworthy that the words stress, strain, pressure, tension and snapping point refer to mechanical and physical phenomena that can be easily measured and quantified yet, although we all know what we mean when we use these words in relation to the human situation, exact definitions and criteria on which to measure them are elusive.

Loss of control?

What exactly do we mean when we say that we, or someone else, is stressed? There is no simple definition because what is seen as a source of stress by one person may be seen as a challenge or opportunity by another. Can we objectively determine whether a person is stressed? Perhaps the only sure indication that a person is under stress is if they say that they are stressed! A principal indication of stress, however, is the degree to which we feel a loss of control of our environment or situation. It seems to be the case that many stressful situations arise from a lack of control in relation to other people who are, in some way, in charge of one's life. This may be an employer, a senior colleague at work or a dominant and demanding person in one's domestic environment. At work, the ever-present threat of redundancy seems to give more power to the bully. Of course, redundancy and unemployment, or the threat of redundancy and unemployment, are themselves important causes of stress and anxiety and it is ironic that numerous people are stressed because they are in the workplace and many others are stressed because they cannot get into the workplace.

Eu-stress and dis-tress

One of the problems in talking about stress is the subtle difference between stress and stretch. It is widely accepted that a degree of pressure is essential for good performance at work but there is a danger that the pressure may get too intense and the quality of work thereby suffer. A cardiologist, Peter Nixon, drew the important distinction between eu-stress and dis-stress.2 Eu-stress is the enthusing and challenging pressure which leads to enhanced performance while dis-stress is the overburdening pressure that leads to depression, fatigue and, ultimately, illness and collapse (see 'The Human Performance Curve'). The problem is knowing when the former becomes the latter for each individual person.

Stress in the healing professions

In talking about stress, obvious areas for concern are the healing professions and, specifically, the British National Health Service as this is not only the biggest employer but is the one service that virtually all people in the United Kingdom encounter, often in moments when they particularly need attention of a nature that a highly stressed person is ill equipped to give.

‘Burnout'

Furthermore, it was within the world of caring, both professional and domestic, that a particular form of stress termed 'burnout', or burnout stress syndrome (BOSS for short) became apparent. This has been defined as 'a state of physical, emotional and mental exhaustion caused by long term involvement in situations that are emotionally demanding'.3 The features of 'burnout' are listed in Table 1 below.

Table 1 Symptoms of 'Burnout'

Junior doctors . . .

Caring, in all its forms, is certainly emotionally demanding and in a recent survey 60% of general practitioners reported that they considered that their physical health had suffered as a result of overwork. There are frequent reports of the stressful nature of being a junior hospital doctor and long hours are the usual cited cause. Looking back on preregistration house jobs in the late 1960s the author is not convinced that this is the entire explanation. Although the hours were long, the pre-registration year was then often considered a fulfilling and enjoyable time. In general, preregistration house officers felt that they were central, respected, and valued members of the team. Also, in those days, junior doctors had little doubt that they would progress up the ladder to senior appointments with relatively little difficulty. Nowadays juniors often remark that they feel that they are little more than skivvies, doing menial jobs including excessive paperwork and playing a very minor role in patient management. A recent survey showed that almost two-thirds of senior medical students and junior doctors wished they had never entered medicine. Indeed, many junior doctors, 25 per cent in one survey, leave the NHS (though not necessarily the medical profession) within three years of qualifying, principally citing burdensome bureaucracy and unacceptable demands related to the Patient's Charter. One such doctor said she left because she had been 'ground down' by the system. Commenting on this, the editor of Hospital Doctor remarked that this 'terrible waste of talents is a loss for us all'. Another junior doctor complained that she 'was treated like dirt' and yet another remarked that he had spent years struggling towards the light at the end of the tunnel, only to find that the light was an oncoming train! At a Meeting of the British Medical Association (BMA), delegates heard 'a litany of psychiatric problems and suicide attempts from representatives'. One doctor who survived a suicide attempt stated that 'I didn't die but I knew others who did for want of someone at the end of a phone who could understand'. As a result, the BMA set up a confidential helpline manned by professional counsellors and is surprised by the extent to which this service is being used.

. . . and consultants

Low morale also affects consultants. A recent report from the Institute of Policy Studies and the North Thames Department of Postgraduate Medicine concluded that 'Without urgent remedial action there is a danger that the NHS will find itself with a deeply demoralised consultant workforce, with an increasing number seeking early retirement or alternative employment'.4 The main reason highlighted for low morale was the increasing sense of disempowerment and disenfranchisement within the NHS Trusts.

. . . and nurses

Anger and frustration are also commonplace in the nursing profession. In a survey (unpublished) of 127 nurses at one London Teaching Hospital, most reported that they felt uncared for by their hospital and said that the atmosphere was dehumanising. When asked if they thought the quality of their work would improve if the hospital adopted a more caring attitude to its staff, 110 replied 'yes', 14 'no' and 3 'don't know'. The great majority thought the hospital should provide some form of staff support, either support groups on the wards or internal or external counselling services. Only 10 said that they never needed to talk to someone about the various human tragedies that they en- countered during the course of their work. Some nurses considered that the hospital Chaplaincy services should embrace staff as well as patients, and in- deed many hospital chaplains now do so. With respect to using such services, half the nurses expressed anxieties over confidence, a third were concerned that resort to such help might earn them a 'black mark' and, much more worryingly, a third said they would not be able to spare the time to receive any available help.

Stress and ill-health

Before discussing the required remedial action, it is necessary to ask what is the effect of chronic stress on the health of those exposed to it? Apart from being very unpleasant for the victim, is there really any evidence that chronic stress can lead to ill-health? Indeed, there is - and so huge is the literature that a review is well nigh impossible. There is considerable evidence linking stress to hypertension and an increased risk of stroke and heart disease and also evidence of associations with other physical symptoms and, of course, depression. Several workers have also claimed a link between the onset of cancer and preceding adverse life events, but the data supporting these claims is limited and controversial.5 The findings of the Health and Safety Executive that as many as one in four employees have become physically or mentally ill as a result of pressure in the workplace have been mentioned above and a number of stress-induced conditions were listed in the HSE report (Table 2 below).

Table 2 Symptoms associated with chronic stress

Managing stress

But what remedial action is needed? Recent correspondence in the British Medical Journal emphasised the need for epidemiologists to focus their attention on the causative factors and determinants of health, as well as disease.6 A review of studies, referred to in that correspondence, on the ability to manage stressful living circumstances and to remain well, highlighted three key contributing factors: comprehensibility, manageability and meaningfulness. This implies that people need to be able to make sense of their lives and what is going on around them, to have a sense of being in control and to have a positive, dynamic approach to life's challenges and opportunities. In this context, the Gospel message is all to do with comprehensibility, manageability and meaningfulness.

In control?

The importance of a sense of being in control on health has been highlighted by an extensive study of civil servants conducted by the International Centre for Health and Society at University College London, which revealed that senior civil servants with a sense of being in control were four times less likely to die prematurely than harassed clerks at the bottom of the career ladder and were significantly less likely to suffer heart attacks, strokes and infections.7 A more recent study in Holland has also attributed the higher mortality rate in the lower socio-economic groups to perceptions of low control.8 Wealth and status is, however, not a direct correlate of health, as some people consciously opt for a non-competitive and non-stressful life or overcome their stress by other means. Professor Pamela Gilles, Director of Research of the Health Education Authority has stated that 'poverty doesn't necessarily mean bad health. What seems to make the difference is outward-looking social networks that help people feel in control'. This challenges the Churches to be the foci for outward-looking social networks.

A test case

As a result of the epidemic of stress-related illness the Health and Safety Executive is urging the Government to introduce legislation to oblige employers to protect their staff from such risk. Indeed, in July 1999 an employer actually admitted, for the first time in an English court, liability for personal injury caused by stress, and damages of over £67,000 were awarded. A professor of law expected that this would lead to a deluge of similar cases and stated that 'employers must learn not to give fewer employees more and more stressful workloads'.

Scratching the surface

So how should stress be managed? Attempts by management to deal with stress often boil down to attempts at palliation which at best are naive and at worst are simply insulting. A senior researcher identified 'low morale, feelings of isolation from colleagues across sites, a lack of feeling of identity within the division and general unrest' within a British medical school. The 'remedy' was the organisation of a black-tie ball which, need it be said, had to be cancelled owing to lack of interest!

Job satisfaction

It is necessary, therefore, to adopt a more rational approach. A Gallup Organisation survey on managers and workplaces led to the conclusion that 'There are no great companies. There are only great workgroups' and delineated twelve factors that led to greater job satisfaction and performance and thereby to greater success of the company (Table 3 below).9

Table 3 ‘Twelve characteristics of Great Workplaces'

All twelve are person-centred factors directly related to communication, encouragement of talents, respect, appreciation and development of skills and abilities. How this contrasts with Theodore Zeidin's comment that 'the healthcare profession contains a vast reservoir of potential going to waste, of talents which are not properly appreciated, and of conversations which never take place'.10 Zeidin adds that 'humans cause themselves a lot of misery bemoaning their limits. But there are ways of expanding our confidence . . .' There are indeed, and the successful employer will strive to do just that.

Addressing fundamental causes

But is there an additional Christian dimension to relief of stress and confidence-building? The quotation from St. Matthew's gospel: 'Come unto me, all you that labour and are heavy laden, and I will give you rest, leads to the conclusion that stress is a very important area for the Christian churches to address - not just through their specific healing ministries but through their entire role in the life of the community. It is indeed a very appropriate area as it embraces healing at the physical and mental levels, healing of human relationships and of breakdowns in family life and social structure. Accordingly, it is the duty and responsibility of Christians to make the Church the place where this pledge of Jesus is fulfilled and is universally seen to be fulfilled. It is important, though, that the Church is seen to address the fundamental causes of stress and not merely to apply the soothing balm of palliation. To quote Sir James Watt, a Past President of the Royal Society of Medicine and a staunch supporter of the Christian healing ministry, on the issue of stress management: 'A more profitable activity for Christians might be to identify and deal with the causes of stress rather than to adopt a palliative for its consequences'.

Is religion stress reducing?

But we live in a highly sceptical age, where the need for proof and evidence is universal. In the NHS, the great in phrase is 'evidence-based medicine'. Is there, therefore, any evidence that, for want of a better expression, 'indulgence in religious activities' has stress-reducing and health-promoting effects? This may be answered in the affirmative as there have, in recent years, been several publications, including a number in front line journals such as the Lancet and the Journal of the American Medical Association 11-16 on the positive impact of religious factors on prevention of illness, coping with any illness that develops and recovery from such illness. In 1995, the National Institute of Health Care Research in the USA organised a conference on the 'Spiritual Dimensions in Clinical Research'12 It was concluded that we can no longer dismiss the importance of religion in recovery from illness and that strong faith can have profound effects on our lifestyles and outlook in terms of health. At this conference a review was presented of twenty-seven studies on the impact of religious involvement on heart disease, cancer, tuberculosis and suicide - all of which may, to varying degrees of certainty, be linked to stress - and only one failed to demonstrate a positive effect: twenty-two gave significantly positive associations and a further four gave positive associations but, on account of their small size, these were not statistically significant.

Not 'whether' but 'how'

The conclusion of the 1995 conference was that 'spirituality and religion have important health benefits and more detailed studies using more accurate measures of these are warranted. The question today is not whether there are health benefits but how these benefits can be obtained. We can no longer afford to neglect this important clinical variable'. One problem encountered in this realm of investigation, highlighted in some detailed reviews, including on in the Lancet, is the great complexity of both health and of religious commitment.11 Many studies have been based on a limited number of measures of health and, sometimes, only one of religious commitment, such as frequency of church attendance - which is not necessarily a direct correlate of a relationship with God. Some commentators, steeped in the prevalent reductionist trend in medical science, see complexity as a barrier to investigation but it is possible to adopt an interdisciplinary perspective - 'Complexity should be seen as an incentive to developing novel ways of working together'.17 Despite the complexity, a recent review in Archives of Family Medicine concluded that: 'A large proportion of published empirical data suggests that religious commitment may play a beneficial role in preventing mental and physical illness, improving how people cope with mental and physical illness, and facilitating recovery from illness'.18 It was, however, stated that much still remains to be investigated and that there is a need for improved studies specifically designed to investigate the connection between religious involvement and health status. Nevertheless, the conclusion was that 'practitioners who make several small changes in how patients' religious commitments are broached in clinical practice may enhance health care outcomes'. More recently, the Health Education Authority has emphasised the importance of faith communities - Christian and Jewish - in supporting those suffering from stress-induced and other mental illnesses.19

Vitalising parishes

From the perspective of the impact of the Church on society, the American journal Health Progress pointed out that health ministries vitalise parishes and help to add meaning to parish community life.20 In Germany, the Church is very much involved in parish health care through the Diakonie movement, which may be one reason Why the Church gives the impression of being more central to community life in that country than in Britain.

Part of the medical curriculum

According to a report in the US Journal of the National Cancer Institute, the role of spirituality and religion in patient management was largely ignored ten or twenty years ago.21 At most, the patient would be referred to the chaplain. Since then, there has been a distinct shift of interest and 99% of US physicians are convinced that spiritual factors contribute to heath and healing and the topic of spirituality and health is included in the curriculum of forty US medical schools, and this is expected to increase to most, if not nearly all the medical schools by the year 2000. One professor of medicine commented that this trend signifies 'an historic reconciliation between medicine and spirituality', adding that the trend reflected an increased interest in spirituality in society at large and a disillusionment over the ability of medical technology to sustain quality of life. As an example of what patients consider important, 93% of 106 women with uterine or ovarian cancers were convinced that the religious dimension of their lives was of help to them, and a half reported a deepening of their religious commitment and faith since becoming ill. Certainly exciting things are occurring in the USA. A commentator in the prestigious Journal of the American Medical Association wrote 'There is at work an integration of medicine with religion, of spirituality with medical practices, the two guardians of health throughout the ages'.13 Sadly, a similar positivism is not so evident in the leading medical journals in the United Kingdom - the very few articles in the British Medical Journal and the Lancet have principally been commentaries, and somewhat reserved commentaries, on the American work. A notable exception is the more cerebral and philosophical Journal of the Royal Society of Medicine which has carried articles on the principles of healing and a report of a clinical trial.22,23

Making the Church relevant

In addition to the difficulties of generating interest in the medical profession, the central question faced in the United Kingdom is how can the Church, which nowadays only attracts a minority of the population, contribute to the health of the community, and be seen to have something really great to offer. This calls for much self-criticism and soul searching by the Church, but there are signs of hope. The Oxford Diocesan Advisory Group for Mission recently held a conference entitled, 'What's Blocking Faith?'. At this conference the question was raised: 'The turbulence and anxiety in our society are painfully clear, so what can the Church do to reach the majority who seem unable to turn to it for answers or comfort?' The speakers at the conference de scribed the 'relentless move towards a stressful, high-pressure, consumer orientated lifestyle' and they delineated the rapid changes in peoples' world view and how their values are formed in today's society. It was pointed out that the modern highly pressurised person is unlikely to take the option of going into an unknown

church as, in spite of their undoubted spiritual hunger, they cannot see that the Church has anything in it for them. A commentator on this conference remarked: 'We know that we (the Churches) have a particular eternal, healing truth to celebrate and to share. But we also know that our structure, style, language and profile do not appeal readily to the majority of the people in Britain.' But at least the Diocese of Oxford is aware of the problem and is taking active steps to address it by a continuing dialogue and consultation. It is the personal experience of the author and numerous other Christians that, just being a Christian and having that unshakeable conviction of being rooted in eternity, puts what could occupy a stressfully central part of one's life in a quite different perspective.

Resources are available

So there is the need, the 'evidence based' remedy and the Divine assurance. What is now needed is for the Church to have the inspiration to put into practice the directions of its Founder. But inspiration alone is insufficient - the individual churches need the 'know how', support and guidance and that is why dedicated groups such as the Acorn Trust and the Guild of St. Raph ael are so important and why the formation of a Learned Society on Faith in Healing and Health Care Provision, as proposed at a conference on Faith in Healing and Health Care provision re cently held at St. Martin's College, Lancaster, could have a very profound impact on the health of the nation. It is perhaps appropriate to conclude by quoting the Revd. Paul Nicolson (in the July 1999 edition of The Door - the Oxford Diocesan newspaper): 'As Christians we are called to stand like living stones to face the complexity and stress of this strange new world, to soak it in a realistic compassion and to innovate, support and implement policies which will relieve suffering and enhance life'.

This is an updated version of an article which appeared in the first edition of 'Sacred Space', a new International journal of spirituality and health, and is reproduced here by permission. It is based on a presentation given by John Grange at the International Conference 'Faith in Healing and Health Care Provision' held at St Martin's College, Lancaster in July 1999.

Notes
  1. Health and Safety Authority. Evaluation of the Organisational Stress Health Audit. London: HSE Health Directorate.
  2. Nixon PG. The grey area of effort syndrome and hyperventilation: from Thomas Lewis to today. J R Coll Physicians Land 1993 Oct.27 (4): 377-383.
  3. Johnstone C. Strategies to prevent burnout. Brit Med J Classified. 1 May 1999: 2-3.
  4. Alien I, Hale R, Herzberg JL, Paice E. Stress among consultants in North Thames. N. Thames Department of Postgraduate Medicine/Institute of Policy Studies 1999.
  5. McGee R. Does stress cause cancer? Brit MedJ 1997;319(7216): 1015-6.
  6. Eskin F. Why people stay healthy. Brit Med J 1997;314(7090): 1347.
  7. Marmot M, Wilkinson R (Editors). The Social Determinants of Health. Oxford: Oxford University Press. 1999.
  8. Bosma H, Schrijvers C, Mackenbach JP. Socioeconomic inequalities in mortality and importance of perceived control: cohort study. Brit Med J 1999; 319(7223): 1469-70.
  9. Buckingham M, Coffman C. Gallup's Discoveries About Great Managers and Great Workplaces. The Workplace Column March 15 - July 7, 1999. Princetown: The Gallup Organization. http:// www.gallup.com/polVmanaging.grtwrkplc.asp
  10. Zeidin T. How work can be made less frustrating and conversation less boring. Brit Med J 1999; 319(7223): 1633-5. 11. Sloan RP, Bagiella E, Powell T. Religion, spirituality and medicine. Lancet 1999; 353 (9153); 1633-5.
  11. Marwick C. Should physicians prescribe prayer for health? Spiritual aspects of well-being considered. J Amer Med Assoc 1995; 273(20); 1561-2.
  12. Mitka M. Getting religion seen as help in being well. J Amer Med Assoc 1998; 280(22); 1896-7.14. Waite PJ, Hawks SR, Gast JA. The correlation between spiritual well-being and health behaviours. Amer J Health Promot 1999; 13 (3); 159-62.
  13. Maltby J. Church attendance and anxiety change. J Soc Psychol 1998: 138(4): 537-8.
  14. Harmon RL, Myers MA. Prayer and meditation as medical therapies. Phys Med Rehabil ClinNAm 1999; 10(3); 651-2.
  15. Porter JDH, Grange JM, eds. Tuberculosis - an Interdisciplinary Perspective. London: Imperial College Press. 1999.
  16. Matthews DA, McCullough ME, Lardon DB, Koenig HG, Swyers JP, Milano MG. Religious commitment and health status: a review of research and implications for family medicine. Arch Fam Med 1998; 7(2): 118-24.
  17. Report. Promoting mental health: the role of faith communities - Jewish and Christian perspectives. London: Health Ed Authority. 1999. 20. Short R. Health ministry vitalizes parishes. Health system helps parishes add meaning to the parish community. Health Prog 1999: 80(2) 36-7 21. Ziegler J. Spirituality returns to the fold in medical practice. J Nati Cancer Inst 1998; 90 (17): 1426.
  18. Hodges RD, Scofield AM. Is spiritual healing a valid and effective therapy? J R Soc Med 1995; 88(4): 203-7.
  19. Dixon M. Does 'healing' benefit patients with chronic symptoms? A quasi-randomised trial in general practice. J R Soc Med 1998; 91 (4): 183-8


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