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Window into CWH: An Awareness Tool

Introduction to CWH

Cognitive work hardening (CWH) is a structured, multi-element occupational therapy treatment intervention that prepares people to return to work after a mental health disability leave [1, 2]. Given the prevalence of work absences due to mental health issues and the paucity of interventions to address the return-to-work (RTW) challenges unique to this population, there is a need for an intervention such as CWH to facilitate enhanced RTW outcomes.

CWH addresses work re-entry issues including fatigue, reduced cognitive abilities, and need for coping skills which are relevant for people returning to work following a mental health leave (e.g., an episode of depression).

While the focus of CWH has been on people off work due to a mental health disability, it has also helped others with similar functional challenges due to sequelae of other conditions including cancer and post-concussion.

A multi-element return-to-work intervention following a mental health disability leave

CWH: A bridge back to work

CWH is designed to prepare people to return to work once their clinical symptoms have improved and they have been medically cleared for RTW. Indeed, in the case of depression, clinical improvement does not necessarily result in full recovery of job performance often due to the residual effects of the depression and associated functional impairments (e.g., fatigue, reduced concentration).

These lags in occupational performance pave the way for a work-oriented intervention to bridge the gap between symptom improvement and work functioning. CWH is such an intervention. Its multi-faceted approach empowers clients enabling them to move beyond a patient identity (that they typically acquired while on disability) to a worker identity (that they typically acquire by intervention completion) - a critical step towards RTW.

CWH is well suited for knowledge workers whose work is mental in nature, involves the manipulation of information, and requires mental power to engage in tasks using cognitive skills such as planning, conceptualizing, and analyzing as opposed to employees whose work requires primarily manual skills.

Occupational functioning often lags symptom improvement
Work-oriented intervention bridges the gap between disability and work functioning

Elements of CWH

Demands Limitations Analysis

The first step in preparing someone to return to work is to understand their job requirements and any limitations they experience which may reduce their work ability. Key to CWH is identifying a person’s occupational performance issues and any other RTW barriers so that the intervention can be customized to their needs and their unique issues.

Focus is on rebuilding cognitive abilities, work stamina, and self-confidence with a view toward employability.

What are the occupational performance issues?

Work Simulations

Central to CWH is the use of work as a treatment modality. This approach is well established within the field of occupational therapy wherein a person’s work tasks and the physical demands of one's job are simulated (as in classical work hardening). CWH builds on this approach and applies the same principle to simulate a person’s work tasks and/or the cognitive abilities required to complete work tasks.

Work simulations are customized for each client. They are designed to be meaningful to the client and to have relevance to their work. Tasks are graded in complexity which can include cognitive load, need for multitasking, and deadlines. Markers of work performance help to identify work strengths and limitations and are instrumental for RTW planning which often encompasses job accommodations needed to facilitate RTW success.

While work tasks are the cornerstone of CWH, ideally they are provided in a setting that approximates a real work environment for maximum impact and benefit. A ‘real-life’ setting is conducive to clients adopting a worker mindset while experiential task mastery fosters an awareness of work abilities and contributes to feelings of self-efficacy.

The progressive work schedule inherent in CWH helps clients establish a routine (often missing while on disability) and adds another dimension to RTW preparation. The gradual increase in work hours together with work simulations helps build work stamina and cognitive abilities consistent with competitive employment. Against the backdrop of a simulated work environment, gains are acknowledged, work potential is recognized and transferability of skills to the workplace is anticipated.

Work simulations are graded and meaningful to client
Work schedule establishes a routine
Re-establishes work stamina and rebuilds cognitive abilities

Coping Skills

RTW preparation involves equipping clients with coping skills that will enable them to better handle stresses at work such as interpersonal relationships, workload, and competing demands.

Education on more effective communication strategies (e.g., assertiveness), time management and goal setting provides clients with tools that they can use once back at the workplace. These help empower clients and build resilience to better handle work stressors which may in fact have contributed to their original leave from work.

Coping skills build resiliency

Ergonomics & Pacing

Rounding out the preparation for RTW, are ergonomics and pacing strategies. Ensuring that clients adopt sound ergonomic principles contributes to minimizing ergonomic risks such as awkward work positions, improper equipment heights, and poor body mechanics which can exacerbate pain and/or discomfort and can contribute to injury.

Pacing is critical to help build work stamina and maintain cognitive clarity and consistent work performance. Pacing includes regular breaks, healthy snacks, and a lunch away from one’s desk. A walk outdoors helps to keep the mind fresh and maximize work efficiency.

Ergonomics and pacing to manage fatigue

CWH Research: Overview

An example of a CWH intervention is the bridge2work™ program that has been offered by ERGO-Wise in Ottawa, Canada since 2000. It has been scientifically studied using a mixed-methods study to (a) evaluate the effectiveness of CWH in preparing people with depression to return to work and (b) identify key elements and main treatment gains of the intervention [3, 4].

Self-report measures were used to compare relevant constructs at the start and end of the CWH intervention. This constituted the quantitative component of the study. Semi-structured interviews with participants comprised the qualitative component.

Work ability, fatigue, and depression severity significantly improved post-intervention. Participants identified structure, work simulations, realism of simulated work environment, support, and education as key intervention elements.

Main treatment gains reported by participants related to routine, self-confidence, stamina, and cognitive abilities with personal agency, empowerment, and skill development emerging as important consequences of the intervention.

Study findings showed improvement in work ability, fatigue and depression severity following intervention

CWH: The future

A wider adoption of CWH ensures that more clients can be helped and RTW outcomes are enhanced. This can be achieved through (i) training of occupational therapists in CWH theory and delivery; (ii) education across disciplines for increased awareness of CWH among doctors, psychiatrists, psychologists; and (iii) consultation with insurance disability carriers and employers to impart the value of CWH for plan members and employees within the scope of their bottom line.

Knowledge transfer to expand the reach of the intervention


[1] Wisenthal, A. (2004). Occupational therapy provides the bridge back to work. Occupational Therapy Now, 6(4), 17-19.
[2] Wisenthal, A., & Krupa, T. (2013). Cognitive work hardening: A return-to-work intervention for people with depression. Work, 45(4), 423-430.
[3] Wisenthal, Krupa, Kirsh, & Lysaght (2018). Cognitive work hardening for return to work following depression: An intervention study. Canadian Journal of Occupational Therapy, 85(1): p. 21-32. doi: 10.1177/0008417417733275
[4] Wisenthal, Krupa, Kirsh, & Lysaght (2019). Insights into cognitive work hardening for return-to-work following depression: Qualitative findings from an intervention study. Work: A Journal of Prevention, Assessment & Rehabilitation. 62(4): 599-613. doi: 10.3233/WOR-192893


Partial funding for this Awareness Tool was provided by the Canadian Occupational Therapy Foundation via the Marita Dyrbye Mental Health Award