Improving Sustainability of Cognitive-Behavioral Therapy (CBT) by Complementary and Alternative Medicine Approaches (CAM) on Reducing Workplace Stress of Teachers

This article argues that the sustainability of cognitive behavioral therapy (CBT) may be improved by the addition of complementary and alternative medicine (CAM) approach in helping teachers reduce their workplace stress. This is demonstrated by two clinical trials testing the effectiveness of a multi-component stress management program with the concurrent use of CBT and CAM approaches developed in Hong Kong. The multi-component stress management is shown to be effective in reducing and relieving stress-related emotional or psychosomatic symptoms. Meanwhile, the self-administered CAM techniques may serve to sustain the effects produced by CBT approach. This has the advantage of saving the additional resources needed from intervention by trained professionals such as occupational therapists and psychologists. Implications and future directions are discussed. *Corresponding author: Professor Hector W. H. Tsang, Neuropsychiatric Rehabilitation Laboratory,Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China, Tel: 852-2766-6750; Fax: 852-3150-8957; E-mail: hector.tsang@polyu.edu.hk Received June 10, 2016; Accepted June 17, 2016; Published June 20, 2016 Citation: Cheung WM, Huang Y, Tsang HWH (2013) Improving Sustainability of Cognitive-Behavioral Therapy (CBT) by Complementary and Alternative Medicine Approaches (CAM) on Reducing Workplace Stress of Teachers. J Pain Relief S4: 001. doi:10.4172/2167-0846.S4-002 Copyright: © 2016 Cheung WM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Short Communication
Teaching, as a profession, is universally considered one of the most stressful occupations [1].Multiple stressors for this occupation include time pressure, teaching workload, curriculum and examination demands, managing student behaviors, nonteaching duties, criticisms from supervisors and inspectors, and lack of recognition and support [2][3][4][5].Work stress is manifested as negative psychological the situation in Hong Kong is even worse because of the frequent education and emotional responses resulting from a discrepancy between the demands and resources, needs, and capabilities [6], which may then trigger a cascade of adverse work outcomes including negative attitude to work, low work performance and teaching quality and hereby student achievements, high dropout rates [7][8][9], and emotional problems such as anxiety and depression [10,11].In addition, stress-related psychosomatic symptoms may occur that consist of abnormal heart rhythms, persistent anxiety, bruxism, headache, insomnia and high blood pressure [4,12], and physical complaints such as tiredness, eye strain, sleep problems, voice disorder, headache, shoulder and neck pain, and lower back pain [13][14][15].

Teaching profession in Hong Kong
Experienced enormous work-related stress with anxiety and depressive symptoms.For example, a telephone survey by Hong Kong Mood Disorder Center [HKMDC] [16] revealed that 15-20% of teachers in Hong Kong had anxiety and depressive symptoms due to vocational strain [17].Hong Kong Professional Teachers' Union [18] reported 13.8% of teachers had anxiety disorder and did not have enough resources or relevant knowledge or skills to cope with these problems.
To help teachers in Hong Kong and around the world cope with their workplace weaken or even disappear once the active treatment was withdrawn.While clinical reforms since 2000 [15].Local studies in Hong Kong revealed that many teachers stress, cognitive behavioral therapy (CBT) seems to be a reasonable option.CBT has been extensively examined and shown to be an effective behavioral therapy for an increasingly wider range of problems such as anxiety, depression, and panic disorders [19,20].It aims to help people be aware of and modify their distorted thinking and hereby develop positive thoughts and behaviors to cope with their psychological distress.However, a frequently raised criticism on CBT is its sustainability in maintaining the resulting desirable behaviors.Fernie, Kollmann, and Brown [21] reported that the outcome of CBT was unstable when compared with other therapies such as emotion focused therapy or relaxation training.Hollon, Thase, and Markowitz [22] suggested that the effects of psychological interventions would substantially weaken or even disappear once the active treatment was withdrawn.While clinical trials showed the limits of long-term effectiveness of CBT, it has at the same time been shown that its combination with other types of therapies would improve the sustainability of its effects and may prevent the relapse of the clinical condition [23].

Improving sustainability of CBT
Complementary and alternative medicine (CAM) has become increasingly popular with more and more users in various professional areas in reducing stress-related physical and psychosomatic responses such as fatigue, sleep disorders, musculoskeletal pain, and mood disorders [24,25].CAM is a group of approaches including biologically based practices making use of the nature substances (e.g., herbs, nutrition, vitamins, and dietary supplements), mind-body medicine enhancing the mind' s capacity to affect bodily functions and symptoms e.g., meditation, biofeedback, relaxation, and guided imagery), manipulative and body-based practice (e.g., massage, chiropractic or osteopathic manipulation), and energy medicine employing the usage of energy fields (e.g., yoga, qigong, acupuncture, etc.) [26][27][28][29].Clinical trials consistently reported positive effects in reducing stress-related effective because of the simultaneous focus on the both well-being and behavioral trails showed the limits of long-term effectiveness of CBT, it has at the same time symptoms such as insomnia and musculoskeletal pain with the use of various CAM approaches [24,25].A systematic review shows that CAM interventions are more effective because of the simultaneous focus on both well-being and behavioral training [30].
Given the limitation of CBT on optimizing and sustaining effects to make a long-term impact on clients [31], my Neuropsychiatric Rehabilitation Laboratory in Hong Kong intended to solve this problem by developing a stress management program using a combined approach of CBT and CAM to help teachers reduce or relieve their stress-related emotional or psychosomatic symptoms, and further improve their perceived well-being, teaching efficacy and job satisfaction.In our intervention, self-administered CAM techniques serve to sustain the effects of stress management and at the same time save the additional time for follow-up contacts between the teachers and the professional trainers [32,33].Based on the model of stress process [34], individuals' stress comes from their appraisal of own capacities being inadequate to cope with the coming demands, and hereby triggering negative emotional responses.The combined approach breaks the stress formation pathway at two levels.First, CBT facilitates more benign appraisal of stress [12,35]; and second, CAM approach helps teachers ventilate and thus relieve the negative emotional and psychosomatic responses.

Clinical trials in Hong Kong
Tsang et al. [33] conducted a quasi-experimental design study to develop and explore the effectiveness of this multi-component stress management program with concurrent use of CBT and CAM approaches.Results showed that, compared with the waitlist control group, elementary school teachers in Hong Kong in the CBT-CAM intervention group had significant reduction in depression, anxiety, and stress, providing the support to the multi-component stress management program in reducing and relieving stress-related symptoms of teacher.
With positive preliminary results, the team conducted another randomized controlled trial and compared the multi-component program using CBT and CAM combined approaches with CBT alone [32].Participants in both the CBT-CAM and CBT only program showed reduced perceived stress level reduced psychosomatic symptoms after intervention.In addition, the CBT-CAM program improved some stress-related physical responses such as handgrip strength and resting heart rate.These findings have deepened our understanding on the causal link between physical function and psychosomatic health, such as the predictive role of lower hand grip strength in the persistence of depressive and/or anxiety disorders [36] and negative relationship between resting heart rate and emotional regulation [37].As more reduction in physical responses was shown in the CBT-CAM group than CBT only group especially during the follow-up period where the active therapy in both more improvement in psychosomatic health and have larger and more sustainable groups was terminated, it is suggested that CBT-CAM intervention would facilitate effects in occupational stress management than CBT only intervention As mentioned above, CBT intervention has questionable sustainable effects, especially when the active treatment period is completed unless there is continuous professional contacts with the participants during the follow up period [22,31].The study by Au et al. [32] has demonstrated that the professional contacts needed for sustainable the positive outcomes elicited by traditional CBT may be replaced by self-administered CAM techniques.The obvious advantage is that these techniques do not require further professional input.The cost-effectiveness and cost-benefits of CBT are then much magnified given the high cost on intervention by qualified professionals such as occupational therapists or psychologists.In conclusion, CBT in combination of CAM approach has the potential of improving the sustainability of the effects produced by CBT alone approach which may in turn save the additional manpower resources.

Ways forward
The multi-component program using CBT and CAM utilized the fundamental aspect of the stress model and attempted to reduce stress using dual pathways.The first pathway is the cognitive appraisal of stress by the individual and at the same time the psychophysiological pathway of the manifestation of negative emotional and physical, emotional and psychosomatic symptoms among the teaching professionals.Meanwhile, it may produce more sustainable effects when compared with CBT alone.Nevertheless, it is at a preliminary stage of investigation which suggests that more attention should be directed towards this research direction of further improving long term effects of CBT by exploring different augmentation strategies such as CAM.To achieve this, more large-scale studies should be conducted with this multi-component stress management program to ascertain the external validity of its clinical effects.Second, it is suggested that further studies should explore the underlying psychological and biological mechanisms of the multi-component stress management program, especially the differential effects of different components of CBT and CAM.Finally, the relationship between physical, emotional, and psychosomatic symptoms and the CBT-CAM interventions should be clarified, hoping that this intervention may be modified and utilized in other kinds of professionals.