BMC Public Health 2009, 9:140 http://www.biomedcentral.com/1471-2458/9/140 from an oral explanation about the rationale, aim, and procedure of the RTW-E programme, patients received a written patient information brochure about the pro- gramme. This information brochure can be downloaded in Dutch or English from http://www.psychischen werk.nl. If the patients accepted the rationale and agreed with the aim and procedure of the RTW-E programme, the programme started. This means he or she learned to cope more actively by gradual exposure to work situations that evoke lower levels of anxiety, stress, or anger, instead of using avoidance behaviour in the case of a stressful work situation. This gradual exposure only concerns stressful work situations that can not be prevented or solved other- wise and are an intrinsic part of the job. For instance, a nurse who is anxious about injecting patients could start her exposure by watching a colleague who is injecting a patient, i.e. being exposed to a similar situation but with a lower level of perceived stress. The patient is motivated and counselled by the OP in order to prepare, draw up, and evaluate an exposure- based RTW plan. This process is structured by giving patients several 'homework' assignments. The homework assignments and accompanying forms A to F support the patient to think about and describe: a. the time he usually spends on different tasks in his job and the current feasibility of performing these tasks (form A), b. a list of stressful work situations that are relevant to returning to work, the extent to which these work sit- uations can be influenced, and how much he tends to avoid these work situations if they could not be pre- vented or solved otherwise (form B). The OP supports the patient in deciding which alternative (active) cop- ing behaviour, instead of avoidance behaviour, will be more effective in reducing his negative feelings in the long term. Applying this alternative coping behaviour in the stressful work situation will serve as a goal in the RTW-E programme, c. various work situations that are similar to the stress- ful work situation but with lower levels of perceived stress. After describing such similar work situations in as much detail as possible, the patient is invited to rank those work situations according to their per- ceived stressfulness. The result is called a stress hierar- chy, in analogy to an anxiety hierarchy for anxiety- evoking situations used in exposure in vivo for anxiety disorders (form C), d. realistic and acceptable RTW arrangements in coop- eration with his supervisor. The RTW arrangements had to consist of a gradual increase in the amount of working hours, feasible tasks, and exposure to increas- ing levels of stress associated with the listed work situ- ations in form C (form D). By practising the new coping behaviour in this way and experiencing several times that he is able to reduce his feelings of stress to an acceptable level without using avoidance behav- iour, the patient will become more confident about his new coping behaviour. The gradual exposure is part of the return to work plan directly from the start of reintegration, e. the evaluation of the RTW arrangements made in form D, in cooperation with his supervisor (form E), f. new additional RTW arrangements in cooperation with his supervisor after evaluating the results of ear- lier RTW arrangements (form F). The homework assignment forms A to F can also be down- loaded in Dutch or English from http://www.psychisch enwerk.nl. Training OPs in the control group We considered the Dutch guidelines on employees with CMDs [34,35] as care as usual. The OPs in the control group received a one-day training in order to update their skills in counselling according to these guidelines. Treatment of patients in the control group Patients in the control group received counselling accord- ing to care as usual (CAU). According to the guidelines, CMD is defined as a (temporary) lack of control of the patient in dealing with his demanding private, working, and health care environment. Therapy and guidance are aimed at helping the patient regain control and rebuild his social and occupational contacts and activities [35]. The OP can reach this goal by using recommended meth- ods such as stress inoculation training, cognitive restruc- turing, graded activity, and time contingency during return to work. CAU meant that patients were informed by their OP about the CAU, which could be supported by a patient informa- tion brochure, 'Nervous exhaustion'. This brochure can be downloaded from http://www.psychischenwerk.nl (in Dutch). If the patient accepted the rationale of the CAU, the OP motivated the patient to prepare, draw up, and evaluate a RTW plan in co-operation with the supervisor. This RTW plan was based solely on a gradual and time- contingent increase in the amount of working hours and feasible tasks. It was not based on gradual exposure in vivo or on a stress hierarchy of work situations at the workplace. This RTW plan was also prepared and struc- tured by giving patients several homework assignments Page 6 of 11 (page number not for citation purposes)