Abstract This study sought to gain a deeper understanding of the types of benefits, programs, and organizational practices employers currently are providing to prevent distress among employees or to help employees become more resilient to adverse conditions. Forty-six employer representatives discussed the perceived strengths of their organizations’ approaches during interviews and discussion groups. Grounded theory methodology was employed to sample and analyze these data. Based on patterns that emerged from the narratives of these participants, a model is proposed to explain three effective approaches used by employers in addressing stress in the workplace: 1) preventing stress/building resilience, 2) providing information, resources, and benefits to employees, and 3) intervening actively with troubled employees. Trust, both in relationships and in organizational structures, emerged as a core concept explaining effectiveness of these approaches. This model may be used to frame future strategies used by employers to support healthy engaged employees and to guide investigations into social and emotional aspects related to work. iii Acknowledgments Finishing a dissertation feels similar to climbing a mountain – looking back on where you have been makes you feel a little weary, but the view from the top is quite exhilarating and immensely satisfying. You also see there are other peaks left to master. I offer warm gratitude to many people who helped me during my climb. To all of the professors over the years who created opportunities for thinking deeply and pondering life’s important questions. To Lisa Mische Lawson for helping to chart my course of study over the years in the Therapeutic Science curriculum and advice during the dissertation process. To my chairperson, Jeff Radel, for hours of reading, editing long sentences, and seeing me through to the end. To Joy Koesten and Jacque Carpenter for their energy and enthusiasm during discussions about coding, analysis, and model building. To my other committee members, Mike Fox and Dory Sabata, for guiding and challenging me and for reminding me that I cannot fit all of my learning into this one document. To the collaborators who helped recruit participants, offered insights, and provided emotional encouragement and input through various stages of the study. These include Sally Baehni (Mid-America Coalition on HealthCare), Marcia Caruthers (Disability Management Employer Coalition), Mary Claire Kraft and Clare Miller (both from the Partnership for Workplace Mental Health, American Psychiatric Foundation), and Teresa Gerard (Blue Cross Blue Shield of Kansas City). To the study participants for their insights, trust, and candor. Gratefully, I thank my family and friends for supporting me, ignoring my occasional vacant stares into the distance in the middle of conversations, and for asking once again, “Just what exactly IS Therapeutic Science?” Thank you for your love and patience through this long journey. iv Table of Contents INTRODUCTION AND LITERATURE REVIEW ...................................................................... 1 METHODS ..................................................................................................................................... 4 Setting and Sample...................................................................................................................................4 Discussions and Interviews ......................................................................................................................5 Data Analysis ...........................................................................................................................................6 RESULTS ..................................................................................................................................... 10 Preventing Distress and Building Resilience .........................................................................................15 Symbols and Guideposts............................................................................................................................15 Workplace culture and practices................................................................................................................16 Strong communication...............................................................................................................................18 Providing Information, Benefits, and Resources ...................................................................................20 Assessment and intervention. ....................................................................................................................20 Concerned participants. .............................................................................................................................21 Building resilience, energy, and engagement............................................................................................23 Actively Intervening with Troubled Employees ....................................................................................24 Disease management programs. ................................................................................................................24 Absence and disability prevention and management.................................................................................24 DISCUSSION............................................................................................................................... 25 Model Summary and Theoretical Basis .................................................................................................25 Implications............................................................................................................................................33 Negotiated professional roles and boundaries. ..........................................................................................34 Leadership and manager roles. ..................................................................................................................38 v Insights and Future Research .................................................................................................................41 Conclusion..............................................................................................................................................42 REFERENCES ............................................................................................................................. 43 Appendix A: Telephone Recruitment Script..........................................................................................53 Appendix B: Participant Information Form ...........................................................................................54 Appendix C: Informed Consent Form....................................................................................................55 Appendix D – Supplementary Participant Narratives............................................................................59 Appendix E: Comprehensive Literature Review I .................................................................................69 Appendix F: Comprehensive Literature Review II..............................................................................120 Appendix G: Comprehensive Literature Review III............................................................................193 List of Tables Table 1: Steps Taken to Ensure Quality and Trustworthiness ...............................................................10 Table 2: Participant Characteristics .......................................................................................................12 Table 3: Characteristics of Participants’ Organizations.........................................................................13 Table 4: Multiple Factors in Biopsychosocial Model ............................................................................29 List of Figures Figure 1: Organizational Approaches to Workplace Stress ...................................................................27 Figure 2: Biopsychosocial Systems Model for Building Workplace Resilience and Engagement .......28 vi Introduction and Literature Review Workers and workplaces have faced considerable challenges in the last several years, including a major economic downturn, natural and human-made disasters, and war. These demands are commonly and collectively called stress. The purpose of the current study was to gain deeper understanding of the types of benefits, programs, and organizational practices employers are currently providing either to prevent stress or to help employees cope with or become more resilient to adverse conditions. Stress has been studied for decades, but terminology for the concept is not consistent. Cannon (1932), a physiologist, examined the way the body mobilizes physiologically for action or escape in response to a threat. He termed this the fight-or-flight response. Selye (1956), an endocrinologist, extended research on the body’s generalized adaptive response to threats and demands. He was the first to acknowledge a distinction between a dissatisfying response to harmful stimuli, which he termed distress, and a euphoric effect of positive adaptation to demands, a state that he called eustress. Over time, the distinction between these two types of responses was lost in both the popular media and the scientific literature. The term stress has become a phrase used interchangeably