Inpatient Psychotherapy of Bullying Victims

Josef Schwickerath and Dieter Zapf

Introduction 593

Indication to Inpatient Treatment 594

Concepts of Inpatient Bullying Therapy 597

Inpatient Bullying Therapy—The Therapy Process 598

Inpatient Bullying Therapy—The Procedure 604

Inpatient Bullying Therapy—The Dysfunctional

Model " 607

Inpatient Bullying Therapy—Perspective and Motto 610

Evaluation of Inpatient Bullying Therapies 612

The Treatment of Bullied Patients—Integrating

Psychotherapy and Bullying Research 618

Bibliography 619


As victims of bullying can develop mental and somatic illnesses (see Mikkelsen et al., this volume), it thus becomes a subject matter in the field of psychotherapy or inpatient treatment (Schwickerath, 2009). In the area of therapy for patients who experienced bullying there is a big research gap with only a fewstudies restricted to quite specific questions (cf. Tehrani, 2003; Vartia etal.. 2003). The therapy concept described in this chapter, which is based on results of research on bullying, has been introduced within inpatient treatment in Germany about 20 years ago. It is still one of the few inpatient therapy programmes for patients suffering from workplace bullying (Schwickerath. 2001, 2009; Schwickerath etal., 2017). The range of treatment is based on special offers for groups in behaviour therapy and the overall programme is distinguished by its goal-oriented procedure. It contains educative units as well as problem-solving-oriented and process-oriented units. What makes it unique is that well-established clinical concepts and clinical experience are linked to findings from bullying research.

Negative effects of bullying on a person’s health often result in unusual symptoms and normally go beyond the findings of most other stress and health studies in work psychology (Zapf and Semmer, 2004; cf. Zapf et al., 1996). In a study conducted by Meschkutat et al. (2002), for example, 43.9 % of targets of bullying fell ill, almost half of these for more than six weeks. Health problems associated with bullying include psychosomatic complaints such as being tense, nervous, having headaches or sleeping problems, experiencing depressive moods, being obsessive, having anxiety disorders and symptoms that resemble posttraumatic stress disorder (PTSD) (see Mikkelsen et al., this volume).

This chapter is based on research and practical work done in the German MEDIAN Klinik Berus, a rehabilitation clinic, where the first author was employed as senior psychotherapist. Between 1999 and 2015, more than 3000 patients with bullying experiences have been treated in the hospital (Schwickerath, 2015). According to German law, rehabilitation should prevent or postpone the ‘impairment of earning capacity’ and accordingly the ‘early retirement from working life’ (Steffanowski et al., 2007). Therefore one of the main aims of therapeutic work is to obtain or re-establish the patients’ ability to work. Every patient is given an initial diagnosis at the beginning of the rehabilitation programme. The main diagnoses for treatment at the clinic (Schwickerath, 2009) show that most of the victims of bullying so far were admitted because of depressive symptoms. The values of depression of bullied patients are comparable to those of other psychosomatic patients (Schiller et al., 2004). However bullied patients show a considerable correlation between job stressors and depression which is not the case for other patients. This is in line with Kivimaki et al. (2003) who were able to demonstrate a relationship between bullying and the occurrence of depression and cardiovascular diseases.

Indication to Inpatient Treatment

This chapter is about inpatient treatment of bullying victims. From our practical experience we know that there are many victims or former victims who would have needed therapeutic help, but did not receive any. However, we know that there are also many victims who are able to solve the problem by other means and, maybe, without any help. Our experiences may reflect the findings of several researchers (e.g., Glasp et al., 2007, 2009; Matthiesen and Einarsen, 2001; Nielsen et al., 2017; Notelaers et al., 2006; Zapf, 1999b; see also Zapf and Einarsen, this volume) who differentiated groups or clusters of victims with differing profiles. It is likely that some of these clusters contain individuals who are likely to seek therapeutic help whereas individuals belonging to other clusters may likely be able to solve the problem without therapeutic help, e.g., by seeking a job in another organization. Thus, what we say about victims and therapeutic help in the remainder of this chapter may not apply to every victim, but it may apply to a substantial group of victims, in particular, for all those who have taken part in a therapy programme.

If patients are to receive a psychotherapeutic treatment, the question is raised whether a special kind of therapy, especially an inpatient therapy, is advisable. An inpatient treatment normally starts with an initial diagnosis carried out by the general or family physician (GP) or a specialist (e.g., according to the International Classification of Diseases. ICD-10). The aim is to clarify if therapy comes into consideration, and, if so, which method should be applied. Although classification systems, like ICD-10 (Dilling et al., 1993; WHO. 2007), or the Diagnostic and Statistical Manual of mental disorders DSM-V of the American Psychiatric Association (2013) provide differentiated descriptions of diseases including detailed lists of symptoms of every disease as well as references to empirical validation (Chambless et al., 1997), these manuals do often not provide sufficient information for the indication of a specific treatment, at least not for the treatment of bullying victims. As disease classifications do not offer sufficient information for a specific treatment, it depends on the consulted doctor which additional criteria he or she will use to favour inpatient treatment. Criteria should include the patient’s imminent loss of earning capacity. Does this require to take the patient out of the pathogenic (work and non-work) environment? Has the patient developed distinctive behavioural deficiencies? Furthermore, is the patient suffering from any co-morbid psychosomatic or psychiatric diseases and finally, will outpatient treatment be enough? (cf. Zielke, 1994, 2011).

As bullying victims experiencing high levels of stress tend to show a poor ability to distance themselves from the bullying situation and to cope with problems adequately (Schwickerath. 2009), the first step to gain distance and become emotionally stabilized is to take them out of the work environment. This is done by signing the patients off sick which would free them from their work duties. Empirical evaluation data shows that signing a patient off sick is often insufficient as the symptoms of many affected persons do not regress solely as time goes by (Schwickerath. 2009; see also the evaluation studies below). Though not being exposed to the bullying anymore, many patients can still not stop ruminating and thinking about the problem without making any progress and without coming up with a solution. This is so because a variety of both organizational and individual factors contribute to the bullying process (see Einarsen et al., this volume). These factors may prevent an easy solution and have, therefore, to be considered in the decision whether or not therapeutic treatment is advisable. On the part of the organization, limited possibilities to communicate, lack of socio-emotional gratification and lack of social support have to be considered. On the part of the individual, the great importance of work in the personal lives of bullying victims which makes it difficult to give up their particular jobs, as well as a strong feeling of injustice and increased sensitivity to rejection make any ‘fast and easy’ solution to the bullying problem almost impossible. Other observable behavioural weaknesses or deficits of bullying victims are an increased proneness to resignation in case of failure, low self-confidence, lack of assertiveness and problem-solving strategies (Schwickerath, 2009; see also Zapf and Einarsen, this volume). These psychological problems and behavioural deficits suggest an inpatient therapeutic setting, which allows the treatment of these problems and accommodates the development of a reasonable perspective for the following years.

The specific characteristics of patients suffering from bullying can be complemented by behavioural aspects of chronic diseases (Zielke and Sturm, 1994). These include, among others, passivity and helplessness, loss of self-management strategies and limited possibilities for passive relaxation. This means, an inpatient therapy is indicated if the following criteria apply:

  • (1) most of the problem areas typical of bullying victims apply,
  • (2) behavioural patterns of chronic diseases have been developed and (3) the patients show a basic motivation and readiness to take on responsibility and deal with the problems related to workplace bullying (Schwickerath, 2011; Zielke, 2011). In that case, an appropriate institution with special treatments for victims of bullying has to be found. Concerning this matter the principle of minimum intervention by Kanfer et al. (2006) is to be taken into account. This principle postulates that a patient’s goal has to be reached using minimum expenditure. In practice, there is often the problem that people who are consulted first by the victims, e.g., the family doctors, have too little knowledge about bullying and its health consequences, and are not aware of the above-mentioned criteria. This makes it sometimes difficult for the victims to get access to a suitable therapy programme.

It should be kept in mind that—at least in Germany— inpatient treatment in a hospital is only possible based on an adequate diagnosis according to the ICD. 'Being bullied’ is, therefore, not a possible diagnosis. In Schwickerath’s (2009) first evaluation study, 73% of the 102 patients received a diagnosis including depressive symptoms, and the largest subgroup was F43.21 ‘adjustment disorder with depressed mood’. Moreover. 68% received a secondary diagnosis, most often musculoskeletal diseases (23%). In the quality reports of the AHG Clinic Berus for the years 2012 and 2013 (Schwickerath, 2015), about 90% received diagnoses including depressive symptoms (N = 364, F32 = 29.9%, F33 = 34.9%; F43.2 = 25.5%). In a second evaluation study (Schwickerath et al., 2017) the main diagnoses included depressive symptoms in 74.1% of all cases, and 17.9% received the diagnosis adjustment disorder. Regarding comorbidity, 87.5% of the patients received at least one further diagnosis.

Concepts of Inpatient Bullying Therapy

The therapy concept of the Berus hospital is based on scientifically founded methods of behaviour therapy, in particular of cognitive-behavioural therapy (e.g., Kanfer and Schefft, 1988; Mahoney, 1989; O’Donohue et al.. 2003). The therapeutic work integrates cognitive-behavioural therapy with results from workplace bullying research. It can be characterized by the following elements: (1) the therapy process including the phases ‘distancing’, ‘understanding’, ‘decision-making’ and ‘taking action’, (2) a specific approach including working on organizational aspects first and thereafter, on the patient’s own contributions to the bullying situation, (3) the formulation of a dysfunctional model (see below) applicable to bullying, (4) the development and examination of a future perspective concerning work as well as other areas of life, (5) specific practical exercises, e.g., in distancing oneself from the problem, (6) further therapeutic measures such as sports or occupational therapy w'hich are part of the inpatient setting (a therapy manual in German can be found in Schw’ickerath and Holz, 2012).

The starting point of the treatment is individual therapeutic contacts of the patients and their therapists being a physician or a certified psychologist. In these initial therapeutic sessions, the motivational preconditions for an active participation in treatments during the hospital stay have to be established. The individual therapy programme has to be developed and coordinated within this setting. Every patient is assigned to a particular therapist who is his or her main contact person throughout the stay in the hospital and who is responsible for all problems, which may unfold during the entire programme. The one-on-one contacts with the therapist provide a basis for individual objectives and therapy steps, which then can also be transferred into activities in group therapy. Weekly supervision sessions by a clinically experienced psychological psychotherapist and a medical specialist assure a broad and differentiated approach to the complex set of psychological and medical problems of the patients suffering from bullying.

In the following, the therapy process will be described, followed by a description of a group therapy concept for bullying patients. In doing so, aims, structure, contents and procedure in the group of bullying patients will be described. Further therapeutic steps will be introduced thereafter. An overview is presented in Figure 19.1.

Inpatient Bullying Therapy—The Therapy Process

As mentioned above, the inpatient therapy or medical rehabilitation of bullied patients in the Berus hospital takes a characteristic course, consisting of the phases ‘distancing’, ‘understanding’, ‘decision-making’ and ‘taking action’, which will be described in the following.

1. Establishing distance: Clinical experience has shown that it is important for the bullied patients to distance themselves from the bullying incidents to be able to focus on a constructive solution of the problem. This was confirmed in an empirical study with victims of bullying having a lower ability to distance themselves from problems at work in comparison to non-victims (Schwickerath, 2009). The stay in the clinic allows to physically and psychologically separating the patients from their problems at work and at home. Although many patients have been on sick leave before the inpatient therapy, a large group is still continuing working before admission to the clinic: 43% in Schwickerath’s (2009) study and 21% in Schwickerath et al. (2017).

This first phase is about acknowledging the issues that concern the patients and addressing them, emotionally stabilizing the patients by providing a therapist who is responsible for them




Selection of Methods

Comprehensive Aspects Explanations

Reference to the phase model by Kanfer et al. (2006)

Establish distance to the

Reception in the clinic;


The phases describe key

1. Initial phase:


bullying situation.

Spatial separation;


aspects; contents also extend



Establish work

Development of a

Euthymic offers

into other phases.

convenient starting



working collaboration

Exercises to practise establishing

Transparency of the therapy



Emotional stabilization

for the therapy,


is important for the bullied

2. Develop motivation


Delivery of information


to change and


Starting point is the

preliminary choice


individual behaviour analysis

of areas to be


as a basis to elaborate therapy goals.

Procedure: from external


aspects to internal aspects.

Comprehensive and central:

Motivation to change




Motto containing the


“What else do I want to achieve in my life?”

FIGURE 19.1 Overview of the bullying therapy.




Selection of Methods

Comprehensive Aspects Explanations

Reference to the phase model by Kanfer et al. (2006)

Elaborate dysfunctional

Individual behaviour

Microanalysis, organizational charts

Therapeutic components:

3. Behaviour analysis


model to understand

analysis and

using a flip-chart, analysis and

Individual therapy

and conditional


the bullying situation


changing of inner forces, image or

Bullying group

functional model


with regard to the

elements to properly

narrative of the dysfunctional model.

Sports therapy


organization, the bully

classify the bullying

approaches of cognitive behaviour



and the patient’s own contributions


analysis, cake model, curriculum vitae,

Four-ears-model; coping with anger, visualization.

Aspects of professional decisionmaking and responsibility (Sonntag. 2016),

triangle of can. should and want, being able to deal with different personality styles, cognitive restructuring

Occupational therapy with work-therapy.

Project group Euthymic offers

Testing of behaviours Relaxation training Assertiveness training Groups with a defined topic (e.g.. tinnitus),

Group cohesion


Clarification of the

Help to find a decision

Technique of columns—pros and cons

4. Agreeing upon








patient’s future professional direction (return to the workplace, transfer within organization, turnover, retirement)

within the elaborated ‘motto’

Image or narrative as a goal (motto)

Decision tree

therapy goals

FIGURE 19.1 (Continued)




Selection of Methods

Comprehensive Aspects Explanations

Reference to the phase model by Kanfer et al. (2006)



Learn to develop abilities /capabilities to put decision into

Problem solving process in terms of self management, coping

Role plays, exercises of distancing, yes-no-exercise, defined ritual.

5. Planning, choosing and executing specific methods


practice; develop problem solving

with stress, encouragement of

acceptance and commitment— therapy, mindfulness exercises.

6. Evaluation of therapeutic progress





competencies; learn strategies of distancing

assertive communication- and conflict—solving behaviour.

Strengthening self confidence and assertiveness,

perception and acceptance of emotions, assertiveness training, problem solving strategies, learning abilities of planning and organising at work, time management.

elements of wisdom therapy, such as “method of unsolvable problems”,

clarifying social aspects, retirement, dismissal, legal measures

7. Final phase: optimizing success, termination of the Therapy

FIGURE 19.1 (Continued) and helping them to establish a therapeutic relationship. It is of primary concern to communicate the therapy rationale and define the working steps of the therapy, based on preliminary decisions with regard to the areas to be changed. In doing so, patients suffering from bullying attend group therapy meetings, referred to as the ‘bullied patients group'. If patients are not able to participate in group meetings from the beginning, they are prepared specifically through individual therapy sessions or by attending purely educational group meetings. In essence, this phase is consistent with Kanfer’s initial phase of role structuring, creating a therapeutic alliance, developing a commitment for change, establishing positive starting conditions, developing a motivation to change and a preliminary selection of areas where change is considered feasible (Kanfer and Schefft, 1988; Kanfer et al., 2006).

  • 2. Understanding: The key feature of this phase is the development of an individual dysfunctional model. This is a model describing the factors contributing to the patients’ problems. A dysfunctional model includes the following parts: A situation— in our case the bullying situation—and thoughts, emotions, bodily reactions and actions occurring in this situation (cf. Figure 19.4). Each of these areas can affect the others. For example, how one thinks about a problem can affect how one feels. With regard to the bullying situation, the dysfunctional model describes the contribution to the bullying problem of the organization, the bully and the patients themselves (see Figure 19.3). The development of the dysfunctional model is done based on individual behaviour analysis which is at the core of behaviour therapy (Kanfer et al., 2006). Additional elements, for instance from systemic therapy approaches, are used in this phase to classify the bullying incident and to support the development of the dysfunctional model for the patient. The main aim is to impart a conflict- or stress-model relating to the bullying problem. Here, the different perspectives of victims and perpetrators are considered (Zapf and Einarsen, 2005), for example, the perspective of a group of perpetrators who in their view only hassle the victim every now and then and who do not attach much importance to their actions, compared to the perspective of victims who consider these isolated actions by several perpetrators to be aimed deliberately and systematically against them. This phase largely corresponds to the third phase by Kanfer et al. (2006), namely the behavioural analysis and selecting target behaviours.
  • 3. Decision-taking: This phase aims to resolve the direction of the patients’ further occupational activities. Can they return

Therapeutic Treatment of Bullying

Taking action



Establishing distance

Motto as perspective

FIGURE 19.2 Therapeutic treatment of bullying.

The conflict model

FIGURE 19.3 The conflict model.

to the former workplace; is relocation to another department or even leaving the organization to be considered? Is there a perspective to find a job elsewhere or is retirement an option? Already being initiated in the previous phases, this decisionmaking process is dealt with once again, most importantly by clarification of the patients’ ‘mottos’ (see below) for the future. Only based on this clarification it is possible to make a sustainable decision. This phase partly corresponds to phase 4 by

Kanfer and Schefft (1988), namely negotiating objectives and methods of treatment.

4. Taking action: The purpose of this phase is the acquirement of abilities or skills to develop a new perspective, which has been worked out in the previous phase. Thereto it is necessary to learn adequate problem-solving strategies as well as strategies to distance oneself. The practise part involves role plays in group-settings and is essential to strengthen selfconfidence and to develop more self-assurance. This phase partly corresponds to phases 5-7 by Kanfer and Schefft (1988): implementing treatment and maintaining motivation with establishing coping skills and strategies, monitoring an evaluating progress, maintenance, generalization and termination of treatment.

Bullied patients, who are often depressive, frequently experience their situation as hemmed in. They need sustainable motivation to change things to be able to escape the limiting and gridlocked situation. Therefore, short- and long-term goals of the patients have to be developed. From our point of viewchanges in behaviour are closely connected to this motivation and the question: ‘What is the use of it?’. The motivation to change and to develop new goals usually affects general goals and values in a patient’s concept of life (Frankl, 1997). To emphasize the importance of developing a new perspective we coined the term ‘motto’ as a label for the new goal.

Inpatient Bullying Therapy—The Procedure

At the core of the therapy programme are the regular sessions of the ‘bullied patient group’. Usually, there are at least eight group sessions. Admission usually takes place in the first and fifth session, as these include educational elements for new patients. The group is led by two experienced therapists and the attendance is limited to 12 participants at most. Group therapy is an effective way to teach the patients knowledge about bullying which is relevant for the therapy. Another advantage of group therapy is the fact that patients feel understood and taken seriously by other members of the group who have made similar experiences, and that they receive social support from the others, which they were lacking so much while they were bullied at their workplace (Zapf and Einarsen, 2005). The group setting acts as a social microcosm where problems are dealt with collectively, where shared personal experiences with bullying play an important part, and where group-dynamic processes among the patients are evoked. This microcosm forms a good precondition for a better understanding of how bullying conflicts develop, and what their antecedents and consequences are.

Before attending their first group session, patients receive information on procedures, rules and goals, which have to be transparent and comprehensible for each patient (see Schwickerath and Holz, 2012). Prerequisites for a constructive group climate as defined by Yalom (1970) are communicated to the patients. Examples for such group conditions are group cohesion, openness, mutual trust and model learning, but also hope and confidence.

The procedure of the interactive group sessions is based on Grawe’s (2002) problem solving approach in which principles of psychotherapy such as problem solving, assessment of the patient's motivation, actualization of problems and activation of resources, are taken into account. As patients come with different prerequisites and different knowledge about bullying, they are given information on the main manifestations, causes and consequences of workplace bullying. Informing about bullying facilitates the entry into the group, as patients partly recognize their personal situation in the general descriptions of bullying. Thus they are able to establish a relation with other group members and learn how to put their personal situation into perspective. They realize that they are not alone with their experiences but rather that others faced similar situations. A ‘common language’ is developed by defining the behaviour therapeutic framework and, thereby, also making the therapeutic procedures transparent. Transparency is particularly important, because bullied patients have often made the experience that they are exposed to ambivalent and non-transparent processes, like being exposed to rumours, unclear instructions, etc. By illustrating the dysfunctional model which has to be developed for every patient, it is attempted to initiate a change of perspective from feeling trapped to a problem-solving attitude. This should help establishing distance and allowing first steps to understand the bullying situation. To persuade a patient of a dysfunctional model that explains his or her bullying situation, it has proven useful to focus on ‘external’ aspects first (organizational problems or structural problems of the organization) before dealing with ‘internal’ aspects, that is the victim’s potential contribution to the bullying process. Firstly the therapist provides general information on bullying, secondly the patient describes the organization or company and, lastly, focus is set on the patient’s own contribution. This course of action is consistent with the patient’s perception that external factors, such as the malicious behaviour of a bully or certain company structures such as conflicting responsibilities, are the main causes of their complex problems (cf. Zapf, 1999b).

In the development of the dysfunctional model the foundation is laid for the patient’s change of perspective, without directly postulating it. Within the behavioural analysis (Kanfer and Schefft. 1988) it is easier for the patients to identify contributions of the organization to the bullying—these are elaborated with the help of organizational charts—and contributions of the bullies. In doing so it is important to keep an eye on the therapeutic process, as described above. In the beginning only indirect references are made to the patient’s own contributions. Understanding the various contributions to the bullying process is the patient’s first step in ‘looking behind the scenes’ of the bullying events. Throughout the therapy the patients’ own contributions are focused on little by little. This implies the message to the patients that a change of how they experience the bullying events can only take place through their own change because this is the only thing which is under the patients’ control. To make the patient's hierarchical position in the organization transparent, an organizational chart is used to point out the relations to the most important other persons on a flip chart. The visual presentation allows a better comprehension of the patient's role for the participants of the bullying group and usually first inconsistencies in the structure of the working situation become apparent. Questions are raised like ‘Who has a say to whom from an organizational point of view?’; ‘How is the hierarchical structure designed?’; ‘Who of the colleagues assigns work tasks to other colleagues at the same hierarchical level thus exerting power which goes beyond the colleague’s formal position?’; ‘What kind of informal roles have developed over the course of time?’

In the following step the bullies’ supposed motives, intentions and problems are brought up and analysed within the group. The analysis of the bullies from the patient’s point of view is less concerned with being ‘objective’ or developing a neutral position, which cannot be achieved anyway, but rather with establishing distance by a form of role reversal. If the patients successfully put themselves in the position of another person, they will learn to put their own behaviour more easily into perspective. The patients have to be treated cautiously and respectfully, as sometimes the stressful memories and still present experiences can make a role reversal impossible. However, other members of the ‘bullied patients group’ often provide suggestions and ideas about the bullies’ possible motives, which can be relieving for the victims, e.g., fear, envy, resentment, competitiveness, but also the so-called ‘unofficial personnel work’ (Beale and Hoel, 2011; Leymann, 1996). The latter refers

Inpatient Bullying Therapy—The Dysfunctional Model

to measures of the leaders and the management aimed at the victim to reach organizational goals by means that are not allowed.

As a third component the patients’ own contributions are elaborated. In doing so things like injured feelings, disappointment, a lack of problem solving strategies or the tendency of not being able to say no, can become apparent. The individual behaviour is analysed while taking personality features into account. The patient's thoughts, emotions, bodily reactions and actions are at the core of the dysfunctional model. It is most important that this model is acceptable, feasible and constructive to the bullied patient.

Behavioural analysis forms the basis for the elaboration of a dysfunctional model, which is the key element of the diagnostic and therapeutic process (Kanfer et al., 2006). The dysfunctional model describes the patient’s problematic behaviour in the bullying process, thereby considering behavioural, physiological, cognitive and emotional aspects (cf. Ellis and Dryden, 2007). This micro-analysis based on the patient’s own contributions concentrates on the four levels of problematic behaviour linked to the bullying events as shown in Figure 19.4). First,


Conflicts at the workplace


Anger, fury Insecurity, shame, guilt Helplessness


"They want to get me down.’ "I cannot handle the rejection."


Components of the victims of


Withdrawal, i solation Offend others Reduced efficiency Concentration problems

Bodily reactions

  • • Tenseness
  • • Exhaustion
  • • Enhancement of psychosomatic complaints
  • • Vulnerability to diseases
  • • Stress reactions
Behaviour analysis at the micro level

FIGURE 19.4 Behaviour analysis at the micro level.

observable behaviour in the bullying process is outlined, e.g., do the patients withdraw, do they isolate themselves from other colleagues or rather irritate their colleagues, will they “attack” and thus start a quarrel thus contributing to the escalation of the conflict? Often concentration and performance problems can be observed. Physical reactions are also recorded; e.g., is the patient tense, are there signs of physical symptoms like headache and/or backache? Second, cognitions or rather automatic thoughts that play a role in a situation of bullying are elaborated. Irrational beliefs (e.g., ‘I’ve got to solve that problem alone’, ‘I have to be well-behaved’, ‘I must not say no.’ etc.) which are a form of automatic thoughts function as internal driving forces. They are associated with the person’s personality and attitude towards work. Third, feelings such as anger, rage, helplessness or fear that the patient has experienced in the course of the bullying events, are both described and actualized within the group session and also recorded on a flip-chart. In many cases the development of the dysfunctional model enables the patients for the first time to perceive their former—often confusing—experiences in a structured manner. This well-directed confrontation with their own case often upsets the patients, but at the same time it offers the possibility to establish distance and to work on the therapy goals. In this early stage of the therapy neither a moral appraisal nor a clarification of the question of legal guilt is of interest. On the contrary, it is specifically pointed out that taking legal measures such as collecting evidence by taking notes and keeping a bullying diary or seeking advice from a lawyer—which is frequently recommended to bullying victims by victim support groups—often impede the clarification of the bullying process from a psychological point of view. Whether or not legal measures will ultimately be taken, is dealt with at a later point of the therapy process.

Moreover, to support the development of the dysfunctional model, explanatory models used in bullying research (cf. Einarsen et al., this volume) are introduced, such as the scapegoat phenomenon (known in the context of social identity theories, Tajfel and Turner, 1986) to assist the patients in understanding their experiences. Another useful element in the analysis of the bullying situation is a differentiated analysis of the patient’s strengths and weaknesses at work. Thereby occupational knowledge, skills and competences (method competence, social competence and personal competence, Sonntag, 2016) are addressed and allow a juxtaposition of the patient’s capabilities and shortcomings. Possible deficits in a patient’s social competence can thus be accepted more easily if at the same time specific professional competences are acknowledged.

Based on this analysis it also helps to resolve the patient’s own expectations from work (‘What is it that I want?’), the expectations of the employer or supervisor (‘What is it that I should do?’) and the patient’s own abilities (‘What is it that I am capable to do?’). The patients can integrate themselves in this triangle of ‘can’, ‘should’ and ‘want’ and hereby identify their own strengths and weaknesses. For instance, a patient can realize that the supervisor decided he or she had to work more than he or she was able to, which can become manifest in feelings of high stress and being experienced as bullying.

In addition the elaborated behavioural analysis is illustrated in various ways, for example, a picture, a concise sentence, a myth or saying, a literary reference, or a narrative (story, novella, cf. Angus and McLeod, 2004) to facilitate memorizing for the patient and to offer the possibility to visualize the tangled situation at any time. Examples of this are: ‘Work as a family substitute’, ‘Loss of work as a kind of divorce drama’, ‘Bullying as a life-long task’ or ‘Prometheus’ as an example of the ancient world.

Due to depressive processing of their problems the bullied patients tend to generalize recently experienced difficulties at work to their entire working life. This often results in seeing their entire occupational career as an ‘experience of failure’. The patients often forget that the bullying events in fact only made up a small part of their previous working life. To help the patients to develop a more realistic perspective, their overall working life is visualized, e.g., with the help of a cake model that has an inedible last piece, namely the time the patient has been bullied. Especially those patients, who almost exclusively regard themselves to be the cause of the problem, are asked to illustrate their previous work experiences in a picture, containing e.g., black for the experienced bullying situation and another colour for the rest of their past working life. It is the goal to develop a realistic, reasonable assessment without playing down the depressive periods caused by the bullying events.

In the course of the bullying analysis the patients resolve the question for themselves whether or not they still fit into the organization or workplace given their individuality, occupational qualifications and capabilities and their new view of the bullying situation they have encountered. It is essential at this state of the therapy to elaborate therapeutic approaches for change and finding ways out of the difficult situation. An indispensable element in cognitive behaviour therapy is reappraisal by cognitive restructuring (Beck, 1976, 1995; Beck et al., 1979; Ellis and MacLaren. 2005), which means identifying dysfunctional or irrational thoughts related to the difficult experience in the bullying situation. The driving thoughts, which influence the bullying experience as an inner force, are elaborated within the group. Examples are: ‘I am responsible for everything’, ‘I am not worth it’ or ‘I have to be better than others’. By thinking the irrational thoughts to the very end, it is pointed out to the patients what it must mean for them to feel constantly responsible for everything. Normally they will realize that life cannot go on like that. When evaluating and classifying irrational thoughts, it has to be kept in mind that the expression of a particular cognitive pattern (e.g., ‘I have to be good’.) was developed to function as a survival strategy within socialization. For instance, ‘being nice to everybody’ could have been a protection against rejection, but an unreasonable strategy to stabilize one’s self-worth. The therapy group is actively involved in the treatment of such irrational thoughts. The goal is to better understand individual reactions and to work on alternative and more functional cognitions, which allow for a ‘better’ coping with life, and, in particular, a better coping with conflicts at the workplace. To achieve long-term coping with the bullying situation, patients learn to answer the following questions: ‘What do I expect of the rest of my life?’, ‘What do I want for the close and distant future?’, and ‘What coping strategies do I want to learn?’. This results in putting into perspective the significance of work compared to other areas of life. It initiates a willingness to accept previous partly vain endeavours and opens new opportunities for the patient. In the end, a balance between job-related requirements, domestic duties and reasonable leisure activities should be worked out with the patient. Helpful are questions like, ‘How did others cope with similar problems?’, ‘What are you going to tell your grandchildren about this incident in 10 years time?’ For the patients a chance to change things also means to break away from old habits or attitudes and learn to reorientate themselves.

Inpatient Bullying Therapy— Perspective and Motto

After building a basis and precondition for coping in the initial phases of distancing and understanding, it is necessary for the patients to develop a perspective or a ‘motto’ for their future career. Priority is given to the answering of two often provocatively asked questions: ‘How much time do I still have left considering the average life expectancy?’ and ‘What do I consider to be important for my future?’ Whereas the patients’ perspective was mainly oriented towards the past during their unsuccessful trials to cope with the bullying situation, the focus is now set on the future. This approach almost resembles a change of paradigms for many patients. This change of paradigm addresses the goals of the patients’ further career and the significance that the patients ascribe to their occupational future. This clarification of perspective and the development of new goals and finding a purpose in life lastly address the patient’s need for a meaning (Frankl, 1997). Thereby, questions of securing one’s livelihood or possibly waiving of financial gratifications play an important role. The patients are to become proactive and to regain control of their lives again instead of remaining patients and victims. They have to let go old patterns of sense-making of their lives and to develop new ones. This future perspective or ‘motto’ is conceptualized in a suitable picture or story (therapeutic narrative) similar to the diagnostic narrative. Examples are, T will make a well-controlled withdrawal’ or ‘I will acquire thick skin’. To resolve the patient’s new perspective, it is helpful to answer the motivational questions by Kanfer and Schefft (1988, p. 128) together with the patient: 1. What will it be like if I change? 2. How will I be better off if I change? 3. Can I change? 4. What will it cost to change? 5. Can I trust this therapist and setting to help me get there? Examples for these clarifications of goals and values can be found in Kanfer et al. (2006). In summary the patients answer the question of 'What forT and decide on their further occupational career.

After taking decisions upon a future occupational direction, e.g., resigning from the company or going into retirement, it is important for the patients to reappraise and translate new plans into action. While doing so the patients should avoid coping by not wanting to have anything to do anymore with their former workplace and to ignore the conflicts. Rather, the patients are explained the importance of an active coping with the unsettled crisis even if they resign from the job. Missing closure or unsatisfactory parting can have the consequence that the pending issues associated with the old workplace close in on the patients over and over again. Overcoming helplessness and finding a sensible closure can happen by a previously settled ritual, e.g., the patient can organize a farewell celebration for former employees with a specific course of events which is also a token gesture toward the bullies.

A series of further elements are integrated into the therapy concept: elements of forgiving (Kämmerer and Kapp, 2006); elements of acceptance therapy (Hayes et al., 1999)—focussing on helping the patients to accept personal characteristics or unchangeable circumstances—and components of wisdom therapy (Schippan et al., 2004). Furthermore role plays are applied to strengthen assertive behaviour (see Fox and Boulton, 2003; Hollin and Trower, 1986). If necessary, problem solving strategies are developed and consolidated (D'Zurilla and Nezu, 2001). Elements of occupational therapy (developing a basic attitude towards work), socio-therapy (qualifications or occupational retraining), sports, movement therapy and relaxation trainings (Bernstein and Borkovec, 1973) complete the therapy (for details see Schwickerath, 2009; Schwickerath and Holz, 2012).

Evaluation of Inpatient Bullying Therapies

In this section we will report on evaluation studies of the therapy programme described above. The first study published by Schwickerath (2009) was based on a sample of 102 patients collected in years 1999 to 2001, that is, the first years when the programme started in the clinic. Measures were received immediately before (Tl) and after the inpatient treatment (T2). Moreover, data from 51 patients collected approximately one year later (T3) could be used for further analyses. Results showed a significant improvement of the patients’ health as indicated in a significant reduction of complaints caused by different health symptoms, depressive moods, psychosomatic complaints and a significantly higher rate of employability. Furthermore a significant increase of having an optimistic point of view could be observed. The descriptive analysis showed that bullied patients were very satisfied with the therapy. Moreover, the patients benefited the most from being able to set themselves new goals and values, which was an important part of the therapy in connection with the elaboration of a long-term perspective ('motto'). As there was no control sample due to practical, legal and ethical reasons, analyses were carried out in reference to subgroups of bullied patients. There were no substantial differences between people who took part in the follow-up survey (responders) and people who did not answer (non-responders).

A first question of interest was, whether the health impairments caused by bullying could be improved if the patients left the bullying situation by being on sick leave or because of being unable to work. In these cases the victims would not be exposed to the bullying any more. No significant differences emerged between bullied patients who worked until they started the therapy programme and were thus continuously exposed to the bullying and those who were not exposed to the bullying situation during the last weeks. These findings were replicated in a second evaluation study (Schwickerath et al., 2017). This could mean that a strict ‘timeout’ alone does not lead to a real improvement of the situation, at least not for those waiting for a therapy. Remaining in an unsettled situation while waiting for a therapy, does not solve the problems for patients who have little distance from the bullying events and lack active problem solving strategies. However, those victims who benefit from stepping out of the nasty game of bullying at an early stage (Zapf and Gross, 2001) because they may not experience the occupational situation as so serious, do not tend to go into therapy. These victims do not necessarily become ill; whereas those who became ill and do not seem to have any possibility to change their situation, are eligible for the therapy programme.

Patients who were examined for a second time after a year (N = 51) could be assigned to the following groups: (1) the ‘changers’ (N = 20): these are patients who took a new job after rehabilitation, (2) the ‘stayers’ (N = 10): those patients who returned to the unchanged situation in their old workplace, (3) The ‘bullies left’ group (N = 7): patients who returned to their old workplace but the bullies did not work in their close environment any more, (4) The ‘retirees’ (N = 8): patients who went into retirement in the year following the therapy and (5) the ‘unemployables’ (N = 6): patients who were not able to work at the time of the follow-up survey. As an example we report the results regarding the development of depressive symptoms (see Figure 19.5).

First of all, the BDI depression scores (Beck’s Depression Inventory; Hautzinger et al., 1995) at time 1 were marginally significant between groups. The ‘changers’ and the ‘unemployables’ showed higher scores than the other groups. No such significant differences occurred at time 2 and time 3. Moreover, all groups showed a significant improvement in BDI scores between T1 (before) and T2 (after the treatment). Significant improvement also occurred comparing T1 and T3 scores (10%-level) with one exception: A significant (10% level) change for the worse occurred for the ‘unemployables’ between T2 and T3.

An interpretation of the data is that all patients except the ‘unemployables’ profited from the treatment, even if they had different base levels. However unemployable patients did neither profit regarding depressive moods, physical symptoms, nor with regard to developing an optimistic perspective of the therapy in the long run. Even though an improvement of BDI scores

Evaluation study

FIGURE 19.5 Evaluation study: BDI scores of different groups of bullying victims.

Note: T1: before treatment; T2: after treatment; T3: 1 year after treatment; BDI: Beck's depression inventory

could be observed directly after therapy, they returned to their base level without an observable trend after being interviewed for the second time. Reasons for these results could be the lack of active coping, which was described in various components of the therapy. The ‘stayers’ compared to the other groups showed lower scores regarding physical symptoms and depressive moods at Tl before the therapy started, and they benefited from the therapy programme as indicated by the significant reduction of BDI scores from Tl to T2. These patients probably returned to their old workplace because the psychological strain was not as distinctive, making it possible to return without greater difficulties and with newly gained coping strategies. The comparatively lower BDI scores could be an indication that the bullying situation of these patients was less severe than the situation of the other groups. Therefore they were able to manage the situation after the therapy.

Patients who changed their employment or were not confronted with the bullies at their old workplace anymore, benefited the most during the course of treatment. Thus, the therapy goal to encourage the patients to analyse their working situation adequately and consider leaving the organization, can be legitimized ex post by our data. This is important, because victims of bullying often feel trapped at their workplace and do not see or consider any possibilities to distance themselves or ways to change their problematic situation. Therefore learning to make a decision in a difficult situation—namely to stay or to leave the organization—is an essential part of the therapy programme.

Another early study evaluated a comparable six-weeks cognitive behaviour therapy programme of the German Vogelsberg clinic (Diivel, 2008) with measures before and after the treatment. As in the study above significant reductions of BDI and SCL-90-R scores were found.

The positive results of the first evaluation study reported above could be replicated in two further studies. Schwickerath (2015) reported data on Beck’s Depression Inventory BDI-II (Hautzinger et al., 2006) of the patients undergone a therapy in the Berus clinic in years 2012 and 2013 and Schwickerath et al. (2W1) provided these data for 2015. All studies reported a significant improvement. Comparing the scores of the Beck Depression Inventory BDI before and after the therapy, a meta-analytical summary of the sample-size weighted Cohen’s d led to an overall effect size of d = .76 (k = 4; N = 531) which comes close to a large effect size (.8) according to Cohen (1992).

Moreover, with regard to the Health-49 (Hamburg modules for General Aspects of Psychosocial Health; Rabung et al., 2009) Schwickerath (2015) reported highly significant changes from therapy start (Tl) to therapy end (T2) with effect sizes of .5 for the 2012 sample (N = 211) and .7 for the 2013 sample (N = 153).

Schwickerath et al., 2017) carried out a replication of the first evaluation study reported above with 112 bullying patients, providing pre-post data, and 67 patients who also provided follow-up data (T3) six months later. As in the first study, a significant improvement occurred when comparing scores before (Tl) and after (T2) the therapy for depression (d = .94) and the symptom check list SCL-K-9 (d = .73). No change could be observed between T2 and T3 six months later. When asking the patients what they found most helpful in retrospect, the ‘feeling of not being alone’ was reported most often (61.2%). Other frequent responses included setting new' goals and values (55.2%). making up a decision (44.8%) and having learned to say ‘no’ (35.8%).

With regard to the ability to work, positive effects were found in both the studies of Schwickerath (2009) and Schwickerath et al. (2017). The respective percentages increased from 43% to 67% and 21 to 30% before and after the therapy. In addition, 9% respectively 13% took part in reintegration measures.

Moreover, the recent evaluation study (Schwickerath et al., 2017) also showed that leaving the organization was the most often chosen option. At time 3, 39% (in comparison to 36% in the first study) remained in the organization whereas 61% (64%) left the organization, either to find a job elsewhere, to be unemployed or to retire.

Comparing the evaluation studies, two differences have to be mentioned. First, the length of stay of patients has been reduced. While a bullying patient in the 2009 study (Schwickerath, 2009) still had an average of 53.4 days in inpatient treatment, the average length of stay of patients in the recent evaluation study (Schwickerath et al., 2017) was 35.5 days. Second, the illnesses of the patients seem more serious in the second study. For example, the BDI cumulative value of the 2009 evaluation study at the time of admission was 17.8, in the second study, the BDI II cumulative score was much higher at 27.1 at baseline. Although, according to the manual of the BDI II (Hautzinger et al., 2006), the sum score of the BDI II is 2 to 3 points higher than that of the original BDI used in the first study, this does not explain the great difference (17.8 vs 27.1) between the studies. This would suggest that patients in the second study were more at risk than the patients of the first study.

We have already pointed out that victims of bullying who are taking part in an inpatient psychotherapy programme are a special group and not representative for all bullying victims. Rather, it is likely that this group is more vulnerable and less able to deal with the bullying alone, compared to other victim groups. Moreover, it is likely that this group suffers not only from bullying but has to deal with other problems as well. This is, e.g., underscored by the worsened health scores of the Schwickerath et al. (2017) study. Kessemeier et al. (2018) analysed a sample of 8.472 patients in rehabilitation hospitals. Of these patients, 31.2% had no job related problems and were not bullied, 52.4% had job related problems but were not bullied, 3.4% were bullied but had no job related problems and 13.1% were bullied and had other job related problems as well. That is, in total, there were 1.391 (16.5% of the total sample) bullying victims among the rehabilitation patients of which almost 80% had other job-related problems as well. This fits well with the high rate of secondary diagnoses for bullying victims described above. Moreover, in this study bullying victims scored higher in depression and anxiety disorders than rehabilitation patients who were not bullied and bullying victims with additional job related problems scored higher than victims without additional job-related problems. Note that the bullying victims of this sample did, in most of the cases, not apply for being treated because of the bullying. This is quite common. Applications for a rehabilitation in a hospital are often submitted because of depressive symptoms (Schwickerath and Kneip, 2004), and bullying is not even mentioned. At the same time, not every psychosomatic rehabilitation clinic in Germany has a special rehabilitation programme for victims of bullying (Schwickerath, 2008).

Further evidence for the multiple problems of bullying victims applying for inpatient treatment comes from a study by Kobelt et al. (2010). They analysed 596 applications (response rate 59.6%) for medical rehabilitation in year 2008 of members of the German Pension Insurance Braunschweig-Hannover. Of this sample, 24.2% were victims of bullying measured by the Trier Bullying Short Scale TMKS (Klusemann et al., 2008). The applications mention both physical and psychological complaints as reasons for the rehabilitation in 55.8% of the bullying victims, but only in 32.5 % of the non-victims. The victims scored substantially higher in SCL depression and anxiety (Cohen’s d = 1.26 in both cases; Kobelt et al.. 2010). Finally, there is evidence that being victimized at school is related to being victimized at work (Smith et al., 2003). A recent representative study (N = 2424) in Germany measured life time occurrence of bullying at school and at work (Brown et al., 2019). Of the participants, 10.6% were bullied at school, 7.1% were bullied at work and 3.3% were both bullied at school and at work. Participants who were bullied at school showed a 10.8-fold increased risk of being bullied at work. Victims of workplace bullying had a 3-4-fold risk of having anxiety or depression disorders, compared to a more than 7-fold risk for those having been bullied both at school and at work. Compared to people who were bullied neither at school nor at work, workplace bullying victims had a 2.9-fold likelihood of taking part in ambulant psychotherapy and a 2.6-fold likelihood for inpatient treatment. The respective numbers for people being bullied both at school and at work were a 6.9-fold and a 10.2-fold likelihood. According to this study there is obviously a strong group with repeated experiences of victimization in their life, and it is very likely to encounter members of this group in inpatient psychotherapy.

Taking the evaluation studies together, we are confident that cognitive behaviour therapy programmes that include findings of bullying research are a capable means to help the victims of bullying. Within a health system, which is under considerable financial strain, monetary aspects of the newly established therapy programme are also of importance. A cost-benefit analysis shows a considerable ‘return on investment’) Wittmann et al., 2002) and the investment into the therapy programme is also profitable considering financial expenses. This is supported by investigations carried out by Zielke et al. (2004), who concluded that investing one Euro in inpatient medical rehabilitation means a long-term gain of over three Euros. The introduced therapy programme offers an effective and efficient therapy for victims of bullying, which is tailored to the particular needs of this patient group.

The Treatment of Bullied Patients—Integrating Psychotherapy and Bullying Research

In the past victims of bullying frequently reported that the psychotherapeutic treatment they received was of little help for them. A reason for this is that psychotherapists tend to have limited knowledge in work and organizational psychology and have thus a limited understanding of workplace conflicts. This also applies for the issue of bullying. In this chapter we tried to overcome this problem by describing a therapy programme that integrates knowledge of work and organizational psychology, and in particular research on workplace bullying, and a cognitive behaviour therapy approach. In the final section of this chapter we will summarize how work and organizational psychology issues and, in particular, findings of bullying research were integrated into the described inpatient psychotherapy programme.

  • (1) Bullying plays a major role in the first phase of the programme where psycho-educative elements are in the foreground. The patients receive an overview on bullying, its definition, typical bullying behaviours, causes and consequences.
  • (2) This knowledge is also used for the analysis of the dysfunctional model. Here, knowledge about organizational structures, and relations with supervisors and colleagues as well as knowledge about the bullying concept is used to reconstruct and subjectively explain the victim’s bullying case.
  • (3) Specific findings such as the victims’ problems to distance themselves from their work (Niedl, 1995; Schmiga and Rammsayer, 2004; Schwickerath, 2009) or the high importance of work to them (Schwickerath, 2009) are integrated into the programme.
  • (4) It is acknowledged that bullying has a variety of causes which can reside in the organization, in the social system at work, in the perpetrator or in the victim (e.g., Einarsen

et al., this volume; Zapf, 1999b). These various causes are used in the analysis of the bullying case. In addition it is taken into account that victims often have difficulties to face their case. To make it easier for the patients the therapy first starts with the organization and then moves on to the patients’ own contributions.

  • (5) It is acknowledged that bullying often is an escalated conflict which is a no-control-situation where a series of otherwise reasonable conflict management strategies have been used in vain and where leaving the organization is often the only option (e.g., Zapf and Gross, 2001). The decision to leave the organization is picked up in the later phases of the therapy and is thoroughly prepared in the previous phases.
  • (6) The change of negative coping strategies (Rammsayer et al., 2006) and the improvement of lowered self-esteem (Vartia, 2003) are taken into account.
  • (7) Finally, transparency is an issue in the therapy, as victims of bullying are very sensitive and easily regard things to be directed against them (Zapf and Einarsen, this volume).

In this chapter we described a therapy programme for bullying victims. Psychotherapy has to concentrate on the individual as there is normally no possibility by the means of the therapy to directly influence and change the organization where the bullying took place. Focusing on the individual does by no means imply that we consider the victim as the major problem in bullying scenarios. However, the victim may also have contributed to the bullying problem and there are reasons to believe that the contribution of victims who take part in an inpatient therapy is larger than the contributions of other victims. But even if it becomes clear that bullying is purely the problem of the organization and of some perpetrators it is still the bullied patients who are treated in the therapy. Their understanding of the bullying, their capabilities to cope with the situation and their physical and psychological health have to be addressed and support may be given to help the patients to consider legal actions against the bullies or their employer.


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Bullying and the Law

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