Work Load and Burnout: Can Social Support and Perceived Accomplishment Help?

Transcription

1 ~~~~~~~Briefly Stated~~~~~~~~ Work Load and Burnout: Can Social Support and Perceived Accomplishment Help? Gary F. Koeske and Randi Daimon Koeske Conceptual and empirical work on burn authors have used various measures of out among professional helpers generally work load, including percentage of time has assumed that excessive work load spent in direct client contact, number of contributes to burnout (Jackson, hours per day with clients, and number Schwab, & Schuler, 1986; Maslach, of weeks that clients were seen (Koeske 1978; Maslach & Jackson, 1981). & Koeske, 1988). Nonetheless, even Presumably, as intense personal contact these more detailed measures were with a client increases, the professional unrelated to burnout (Krowinski, 1981). helper's risk of developing burnout in The absence of reliable correlations creases. The expectation that excessive between work load and burnout may work load acts as a probable antecedent not result solely from inadequate defini of burnout seems obvious but has proven tion and measurement of work load. difficult to substantiate. Also, caseload Overly simplistic and incomplete and work load are not always inter models that relate work load to burnout changeable. probably also contribute to the con Although Maslach and Jackson (1981) tradictory results. In the study reported reported that caseload size was related in this article, the authors addressed significantly to burnout, as measured by such research inadequacies by using the Maslach Burnout Inventory (MBI), multiple measures of work load that this finding has received little corrobora acknowledge the complex demands tion since. Using data collected by placed on workers by client contact, by Koeske and Koeske in 1980 and 1981 specifying social support and a sense of (1988), Krowinski (1981) examined personal accomplishment in one's work caseload size as well as other objective as contingent factors that may moderate indicators of work load in two related the effect of work demands on stress studies of social worker burnout. Of 12 and exhaustion, and by introducing work load-burnout relationships tested, work stress as a factor that mediates the only one was statistically significant work load-burnout relationship. caseload size correlated significantly A heavy work load represents a with burnout (r =.42, P <.01)-and demanding environment that, under this significance occurred in only one of certain conditions, will place the social the two studies. In the second study, the worker under stress. A continuing con same relationship did not approach dition of high stress places the social significance (r = -.12). Jackson et al. worker at risk for emotional exhaustion. (1986) also found caseload unrelated to If the stress is not corrected or burnout and speculated that Maslach's ameliorated, the social worker may ex earlier correlation might have been perience a loss of morale, plan to leave spurious. the job, or develop psychological and Caseload size is not a simple and physiological symptoms. The classic straightforward variable, particularly in model of stress developed by Selye relation to burnout. The meaning of (1956) suggests that environmentally caseload varies with the nature of the provoked stress that continues over work setting and with critical character time may produce a series of responses istics of the clients. Large caseloads that include exhaustion. may not involve intense client contact. As defined in this article, work load is To assess these complexities, the an environmental stimulus condition that can be measured with objective indicators of demand. Work stress refers to concrete events perceived as troubling, hassling, and unpleasant that are reported to have occurred in the workplace. The level of work stress experienced is a function of the number and intensity of such troubling events. Burnout, or emotional exhaustion, is a negative affective response by the social worker to work stress-a sense of depletion and deep fatigue. All three concepts were defined and measured to relate specifically to work settings involving intense personal involvement and contact with clients. Researchers have found some evidence for the correlation of various measures of work stress (for example, role ambiguity, role conflict, and lack of autonomy) with the MBI measure of burnout (Constable & Russell, 1986; Himle, Jayaratne, & Chess, 1986; Jayaratne, Tripodi, & Chess, 1983; Johnson & Stone, 1986). Although such findings can be useful practically as well as scientifically because they seem to help identify correctible environmental contributors to burnout, the evidence they provide is not maximally convincing. In particular, when work stress is assessed by reports of concrete occurrences (such as "I was criticized by my supervisor for a decision I made" and "One of my clients attempted suicide") rather than by subjective judgments (such as "I am often confused about what is expected of me in my job" and "I am not given the freedom to make my own decisions"), the assessment more closely reflects identifiable events in the work environment, not just perceptions and feelings that may be internal to the social worker. Measures of the latter (judgmental) type also are more likely to share method (error) variance with the negative self-reports of exhaustion that contribute to the MBI. Such sharing of method variance might yield inflated estimates of stress-burnout relationships and could lessen the conceptual clarity of the burnout construct (Campbell & Fiske, 1959). CCC Code: /89 $ , National Association of Social Workers, Inc. 243

2 With respect to the moderating role of social support, social workers who feel emotionally and practically supported by significant others at work and at home likely will be able to endure demanding workloads with less impairment than their poorly supported coworkers. A similar advantage may be expected for social workers who possess a sense of personal accomplishment regarding their work. In this second case, an overload of client contacts probably would induce less stress if the social worker sensed that intended positive client outcomes were being achieved. Thus, social support and a sense of personal accomplishment are two conditions or resources that may act as buffers against the debilitating stress response that burned-out helpers manifest. That work stress will have negative consequences only or mainly when social supports are insufficient is a special case of the "buffering hypothesis," which has received considerable attention in the vast life stress and social support literature (Cohen & Wills, 1985; Payne & Jones, 1987; Turner, 1983). Including personal accomplishment as a buffer results from defining the burnout construct in a new way (Koeske & Koeske, 1988, in press). In the redefinition discussed in this article, which has received some empirical support, burnout is measured by the Emotional Exhaustion subscale of MEl; the other MEl subscales, Depersonalization and Personal Accomplishment, represent other variables related to burnout. As mentioned earlier, accomplishment may moderate the impact of burnout on negative work consequences, such as job dissatisfaction and intention to quit (Koeske & Koeske, in press). Social workers who feel effective in their work efforts (as reflected in higher personal accomplishment scores) possibly are able to endure a more demanding work load without suffering burnout. A variety of objective workload indicators affect level of burnout. To measure this level, the imprecise notion of "caseload" was defined with concrete indicators. In addition, the authors evaluate the buffering hypothesis-that work load demand will have a more pronounced effect on burnout for social workers whose social supports are insuf- 244 ficient and for social workers who lack a sense of accomplishment with their clients-by examining the interaction of work load with social support and personal accomplishment. The authors also evaluate the notion that the work demand-burnout relationship is mediated by work stress. In other words, stress is postulated to be the mechanism by which work demands place unsupported and ineffectual social workers at risk for burnout. Methodology Two separate studies tested the main and interactive effects of work load. The data for study 1 (n = 125) derive from two samples of respondents who participated in similar questionnaire studies conducted in 1980 and 1981 (Koeske & Koeske, 1988). Unlike study 2 (n = 91), which was conducted in 1988, study 1 did not include a measure of social support and was not designed specifically to test any buffering hypothesis. However, both studies' samples did share four objective work load indicators and MEl, including the emotional exhaustion subscale and the personal accomplishment subsca1e. Relevant study 1 data were reanalyzed to enrich the test of the hypotheses for which the study 2 data were collected. Study Samples Identical sampling procedures were used in studies 1 and 2, both of which were questionnaire studies of social workers' beliefs and reactions. Employed, part-time evening students in the University of Pittsburgh's MSW program generated a list of social workers in their current work settings who were engaged in direct client contact. If the student's list contained six or fewer social workers, the student approached each worker on the list as a potential respondent; if the list included more than six workers, the student randomly sampled six workers. The respondents, who were assured anonymity and confidentiality, sealed their completed questionnaires in a preaddressed envelope. The rates of return were 88 percent for study 1 and 94 percent for study 2. Given the wide range of agencies in which students were employed, this quasirandom sampling procedure produced a broad and roughly representative sample of Pittsburgh-area social workers. In study 1, 67 percent of the respondents were female, with a mean age of years and an average of 4.72 years in their current job. In study 2, 71 percent of the respondents were female, with a mean age of and 5.29 years of experience in their current job. Measures Burnout and Personal Accomplishment. Although the questionnaires employed in both studies included MBI, no overall burnout score was used. Instead, scores on emotional exhaustion (a nine-item subscale) and personal accomplishment (an eight-item subscale) were compiled separately. (The five-item depersonalization subscale was not used in this study.) Emotional exhaustion was used as the measure of burnout (the dependent variable), and personal accomplishment was used as a moderator variable. The standard seven-step frequency format was used for MEl in study 1; the scale was shortened to five steps for study 2. Construct validity for MEl and acceptable reliabilities for the subscales have been well documented elsewhere (Koeske & Koeske, 1988; Maslach & Jackson, 1981). For both the study 1 and study 2 samples, the Alpha reliability coefficient for the emotional exhaustion subscale was.90. The Alpha reliability coefficients for personal accomplishment were.71 and.73 for studies 1 and 2, respectively. Work Load. Four categories were used to assess work load in both study 1 and study 2: (1) average hours per day of direct client contact, (2) percentage of total work time spent in direct practice, (3) percentage of interventions that were of a crisis nature, and (4) percentage of interventions that were of an intensive nature. Four additional items were used in study 2: (1) average number of hours per week spent in primary social work job, (2) average number of hours per week spent in other human service activities, (3) percentage of work day spent in direct client contact, and (4) number of clients (individuals, families, or other Social Work I May 1989

3 Table 1. Means, Standard Deviations, and Correlations with Burnout (y.) for Each Work Load Question Asked in Study 1 and Study 2 Study 1 Study 2 Work Load Question Mean SD r. Mean SD r. On the average, how many hours a week do you work in your primary social work job?a On the average, how many hours a week do you spend in other human service activities~ What percentage of your work day is spent in direct client contact~ How many clients (individuals, families, and other client systems) do you see in a typical day?a In general, how many hours per working day do you spend in direct client contact? What percentage of your interventions with clients are intensive? " What percentage of your interventions with clients are crisis? What percentage of your working time is spent in direct practice? "P <.05 ~estion not asked in Study 1 questionnaire. client systems) seen in a typical work day. These particular measures were developed to assess work load conditions that were direct, intense, and involved contact with clients (Table 1). Social Support. Respondents in study 2 rated the amount of emotional and also the amount of practical support they received from six categories of persons: (1) spouse, (2) children, (3) other family/relatives, (4) friends, (5) coworkers, and (6) supervisor. These 12 ratings were made on a five-point Likerttype scale that ranged from 1 ("none at all") to 5 ("a great deal"). Respondents circled "not applicable" if they did not have a person from the category in their social network. Scores were summed across appropriate ratings and an average was computed across the answered scales to reflect "total support." Averages also were computed across emotional and practical support for coworker support, spouse support, and supervisor support. The Alpha coefficient for this scale was.86. Work Stress. A measure of work stress, the Work Occurrences Inventory, was developed based on the research of Motowidlo, Packard, and Manning (1986), whose instrument was designed to measure stress in a sample of nurses. Respondents indicated how frequently each of 40 "troubling occurrences" had Briefly Stated happened in the past 2 months. Sample troubling events included the following: "A client of yours commits suicide," "You miss work due to a health or personal problem," and "You have a conflict with a coworker." The respondent circled "no" (scored 0) if the event had not occurred; "yes" (scored 1) if the event had occurred once, and "yes + " (scored 2) if the event had occurred more than once. Results and Discussion The mean burnout score in study 1 was 2.38 (based on a seven-step scale) and 2.70 in study 2 (based on a five-step scale). Average scores for the personal accomplishment subsca1e (scored in a positive direction) were 6.23 (of 7 total possible) in study 1 and 3.88 (of 5 total possible) in study 2. In study 1, therefore, scores that indicated burnout and a sense of failure were very low, and study 2 scores were more in the moderate range. These differences may be the result of the change of metric used in study 2, of sample differences, or of increased burnout over time. The current study was not designed to address this issue. What is apparent is that average burnout is not high in an absolute sense in the study samples, which is to be expected for individuals currently working at their jobs. The means and standard deviations for the work load variables for studies 1 and 2 as well as the correlations of these variables with the emotional exhaustion subscale were calculated. The study 1 and study 2 samples are similar on three of the four common work load variables but are different on hours per day of direct client contact. The 1988 sample reported about 2.5 more contact hours. The simple (zero-order) correlations of the four common work load variables with burnout were small, except the -.28 correlation for percentage of intensive interventions found in study 1. This correlation, like that for hours per day of direct client contact (-.14), was not in the expected direction-that is, a greater percentage of intensive interventions was associated with less burnout. The four additional work load-burnout correlations available in study 2 all were less than.20. In terms of simple correlations, then, little evidence was found for a predictable or consistent impact of work load on burnout. The absence of significant and substantial main (direct) effects of the work load variables on burnout, though perplexing from the viewpoint of theory or simple common sense, is not surprising given the dearth of past evidence for such relationships based on objective indicators. The absence of direct effects is not unexpected, however, if the impact is considered conditional, as predicted in this study. To determine whether the work load variables produced burnout, particularly for social workers who lacked social supports or a feeling of efficacy with clients, moderated multiple regression analyses, which used deviation scores as suggested bycronbach(1986), were carried out (Norusis, 1985). This rather conservative analytic approach involved entering predictors of burnout in the following order: work load variables (step 1); moderator variable (either social support or accomplishment) (step 2); and interaction product terms (that is, work load x moderator variables) (step 3). Finding a significant increment in explained burnout variability (J?2) when the interaction term was stepped in indicated that the effect of work load was qualified significantly by (that is, conditional on) the moderator variable. 245

4 Table 2. Beta for Interaction Using Social Support (Study 2, n = 91) and Personal Accomplishment (Study 1, n = 125; Study 2, n = 91) as Moderator Variables Work Load Question On the average, how many hours a week do you work in your primary social work job? On the average, how many hours a week do your spend in other human service activities? What percentage of your work day is spent in direct client contact? How many clients (individuals, families, and other client systems) do you see in a typical day? In general, how many hours per working day do you spend in direct client contact? What percentage of your interventions with clients are intensive? What percentage of your interventions with clients are crisis? What percentage of your work time is spent in direct practice? Social Support Personal Accomplishment Study 2 Beta Study 1 Beta Study 2 Beta (W x S) (W x A) (W x A) * * -.22* -.27* **.10 *P <.05, **P <.01. NOTE: The Beta is the partial regression coefficient for the interaction of the work load variable with social support (or accomplishment) in the analysis, which included all work load items present in that study. All significant interactions were consistent with the buffering hypothesis. Social Support as a Buffer of Burnout In study 2, the main effect of the eight work load variables (step 1) was not significant. Adding the main effect of support to the predictor equation (step 2) increased the explained variance by.06 (p <.04), consistent with the -.25 correlation of support with burnout. The addition of the work load by support interaction terms (at step 3), however, increased the W from.39 to.63 (p =.016), which indicated that work load had no direct effect on burnout but quite a substantial effect when the moderating impact of support was considered. Partial standardized regression coefficients ({3) for each of the work load interaction terms indicated that a significant moderating effect (p <.05) of social support on work load was found for hours per day of direct client contact and for percentage of crisis clients (Table 2). A supplementary analysis, in which the interaction effects were estimated in separate regression analyses for each work load variable, showed that the variable for number of clients seen in a typical day interacted significantly with support. The standardized regression coefficient for this variable (-.18), 246 though not significant at the.05 level, was sufficiently large to be regarded as a critical work load variable as well. Comparison of the correlations found between work load and burnout under low support (below the median) versus high support (above the median) revealed that each interaction was of the buffering type. For example, the correlation of number of clients in a typical work day with burnout when social support was low was +.35, compared with -.11 when support was high. That is, the two variables were significantly related under low support but unrelated under high support. For each of the three measures, heavy work load produced more burnout, but only when social support was low. Followup analyses showed that this significant buffering effect was clearly reflected only in support provided by coworkers for which the interaction effects that involved number of clients (p =. 037) and percentage of crisis clients (p =.005) were significant. None of the variables was even marginally significant for supervisor support, and only number of clients showed a significant buffering interaction(p =.015) for spouse support. Overall, then, there is good evidence that social support, particularly that supplied by co-workers, can buffer the negative impact of work load on burnout. The elements of work load most relevant to burnout (under low support) were the number of clients seen in a typical day, the average hours per day spent in direct client contact, and the percentage of crisis interventions. Accomplishments as a Buffer of Burnout Similar regression analyses were carried out with personal accomplishment as the moderator variable. In the study 2 data, little support was found for the buffering effect of personal accomplishment. Stepping in the interaction terms elevated the W by only 9 percent, which was a nonsignificant increment(p =.41). The only significant individual work load term was that obtained for percent of crisis clients ({3 =.27, P <.05). This interaction did reflect a buffering effect. Tests on the study 1 data of the moderating impact of personal accomplishment revealed an increment of 9 percent in W because of interaction that was significant (p <.02). In addition to the percentage of crisis clients, which was the single significant work load variable in study 2, time in direct practice had a significant standardized regression coefficient (p <.02 for each variable). Correlational analyses showed that the percentage of crisis clients related +.21 to burnout for workers with a low sense of accomplishment, but -.15 for those with a high sense of accomplishment. In other words, crisis-type interventions seemed to produce increased burnout only among social workers who believed that their efforts were ineffectual. Because this variable was the only one to be buffered significantly by accomplishment in both studies (separated in time by more than 7 years), the effect appears to be genuine. Nonetheless, the evidence for a buffering impact of personal accomplishment was very specific and limited compared with that for social support. Mediating Role of Stress The second objective was to determine whether the impact of work load on burnout occurred via the proposed mechanism of work stress-that is, whether Social Work / May 1989

5 Figure 1. Effect of Work Stress on Work Load-Burnout Relationship, Controlling for Support Low Social Support Percent Crisis.34" Work.59'" ---i~~s'tress ~ Burnout Number of _.4_8_"-4'.~Work _._5_9'_'-t' ~~ Burnout Stress Hours Direct ~ Work.59"~ Burnout Contact Stress 'p<.10, "p<.05, '''p<.01 work load led to stress and then to burnout under conditions of low support or low accomplishment. Statistical evaluation required controlling for stress by introducing this variable into the regression equation before introducing any interaction terms. If stress represents the mechanism by which work load affects burnout under conditions of low support or accomplishment, then the previously significant work load x moderator variable effects should become nonsignificant when stress is controlled for or "removed." That is, work load results in burnout (under conditions of low support or accomplishment) if and only if it produces stress. Analyses that evaluated the mediating effect of work stress consistently showed that the standardized regression coefficient and incremental R2 for the previously significant interaction terms that involved social support or accomplishment became nonsignificant when the impact of stress was removed. For example, the standardized regression coefficient for the interaction of Briefly Stated High Social Support Percent.58'" Crisis -.03 h Work ---ih~ Burnout ~Stress.. Number 09 Wo k.58*** of -. ~ r ---i~~ Burnout Stress Hours -.25 Work.58'" Direct -~.~ Stress ~ Burnout Contact number of hours per day of direct client contact with total support was -.28 (p =.03) when the mediating effect of stress was not considered. After controlling for work stress, the corresponding standardized regression coefficient was -.15 (p =.22, not significant). These results show that stress was indeed the mechanism that linked work load to burnout. Work stress has a mediating effect, and support and accomplishment have a moderating impact on the relationship between work load and burnout. The correlations follow a path from the work load variable through work stress to burnout. Only for the low social support (Figure 1) and low accomplishment (Figure 2) conditions does work load produce significantly greater stress. In no case was high work load related to work stress when support or accomplishment were high. In fact, a slight, nonsignificant tendency existed for demand to relate to less stress when support and accomplishment were high. In every case, work stress correlated highly with burnout. Consistent with the mediating role of work stress under low support and accomplishment conditions, the partial correlations of the work load variables with burnout, when the calculations controlled for work stress, were not significant and ranged from 0 to.13. Work load showed no significant direct effects on burnout-the effects, as predicted, were mediated through work stress. Conclusion and Summary The data showed that, under certain conditions, demanding work loads were associated with worker burnout. The most critical condition was low social support, particularly low coworker support. A secondary condition was a perception of being ineffective with clients, which may impair only social workers who offer short-term crisis interventions. The data suggest that building a socially supportive work environment may forestall social worker burnout in social service settings. Such interventions may be important for providing emotional relief and reducing social worker turnover. The demonstration that work stress mediates the impact of work demands on a vulnerable social worker's risk of burnout is important for a more encompassing theory of burnout. Most previous research, even that with a hypothesis-testing focus, has evaluated simple bivariate predictions. The research presented in this article has tested a fairly complicated model of burnout that involves both predictions of moderated and mediated variable effects. The theoretical enrichment made possible by this approach can help researchers and administrators to focus on viable intervention alternatives. For instance, interventions designed to affect social support systems, social workers' feelings of efficacy, and stress in the work environment are provided theoretical grounding by the reported results. The individuals sampled in this study were relatively heterogeneous, including social workers from diverse agency settings (public, private, and nonprofit private) who provided health, mental health, family, children's, criminal justice, and other services. However, the sample was restricted to a three-county area in western Pennsylvania and was 247

6 Figure 2. Effect of Work Stress on Work Load-Burnout Relationship, Controlling for Accomplishment Low Personal Accomplishment Percent Crl sl s _..;..:..44:... ~.. ~ Work.58.. Burnout po Stress' po.p<.01 not derived by formal probability sampling. Conventional probability sampling employed in a mailed survey with an instrument the length of the one used in this investigation might result in a return rate of less than 60 percent, which would introduce the possibility of bias. However, replication with conventional sampling could enhance the findings by increasing their generalizability. A longitudinal design would allow confirmation of the causal flow suggested, particularly of the mediating role of work stress. Social service administrators should realize the contingent nature of the impact of work load demonstrated in the data. Overall, demanding work loads apparently are not associated with negative consequences may be deceptive. Only social workers who lack support or feelings of accomplishment may show imediate or early deterioration, while some well-supported or efficacious workers may endure without apparent effect. Future research should be directed not only toward verifying these contingent effects but also toward examining to what extent work demand and burnout actually interfere with clinical effectiveness. Although research has shown that burned-out social workers dislike their jobs and express intentions to quit (Koeske & Koeske, 1988), no research is available on whether they deliver less effective services. Research and practice would benefit from an integrative theory that advances the conceptualization of burnout and from research that demonstrates whether interventions designed to 248 High Personal Accomplishment Percent Work 55. Crisis _.-,-.1..;.9--1.~ Stress Burnout ameliorate burnout produce intended effects. The authors have attempted to test elements of a model of burnout (Koeske & Koeske, 1988). Burnout can be redefined as emotional exhaustion or strain that results from client involvement. Presumably, this strain results from various sources of stress in the work environment and in turn generates negative outcomes (such as job dissatisfaction and intentions to quit). The likelihood that such strain will result from stressors and lead to negative outcomes depends on factors like social support and personal accomplishment. Advances in burnout theory will facilitate more rational and effective interventions with social workers and clients. References Campbell, D. T., & Fiske, D. W. (1959). Convergent and discriminant validation by the Multitrait-Multimethod Matrix. Psychological Bulletin. 56, Cohen, S., & Wills, T. A. (1985). Stress, social support and the buffering hypothesis. Psychological Bulletin, 98, Constable, J. F., & Russell, D. W. (1986). The effect of social support and work environment upon burnout among nurses. Journal of Human Stress, 12, Cronbach, L. J. (1986). Statistical tests for moderator variables: Flaws in analyses recently proposed. Psychological Bulletin, 102, Himle, D., Jayaratne, S., & Chess, W. (1986). Gender differences in work stress among clinical social workers. Journal of Social Service Research, 10, Jackson, S. E., Schwab, R. L., & Schuler, R. S. (1986). Toward an understanding of the burnout phenomenon. Journal of Applied Psychology, 71, Jayaratne, S., Tripodi, T., & Chess, W. A. (1983). Perceptions of emotional support, stress, and strain by male and female social workers. Social Work Research & Abstracts, 19, Johnson, M., & Stone, G. L. (1986). Social workers and burnout.fournal of Social Service Research, 10, Koeske, G. F., & Koeske, R. D. (1988). Struc tural and theoretical validity of the Maslach Burnout Inventory: A critical review and reconceptualization. Manuscript submitted for publication. Koeske, G. F., & Koeske, R. D. (in press). A preliminary test of a stress-strain-outcome model for reconceptualizing the burnout phenomenon. Journal of Social Service Research. Krowinski, W. J. (1981). A construct validation study of the Maslach Burnout Inventory. Unpublished manuscript, University of Pittsburgh, Pittsburgh, P A. Maslach, C. (1978). Job burn-out: How people cope. Public Welfare, 36, Maslach, C., & Jackson, S. A. (1981). The measurement of experienced burnout. Journal of Occupational Behavior, 2, Motowidlo, S.]., Packard, J. S., & Manning, M. R. (1986). Occupational stress: Its causes and consequences for job performance. Journal of Applied Psychology, 71, Norusis, M. J. (1985). SPSSX advanced statistics guide. New York: McGraw-Hill. Payne, R. L., & Jones, J. G. (1987). Measurement and methodological issues in social support. In S. V. Kasl & c. L. Cooper (Eds.), Stress and health: Issues in research methodology (pp ). New York: John Wiley & Sons. Selye, H. (1956). The stress of life. New York: McGraw-Hill. Turner, R. J. (1983). Direct, indirect, and moderating effects of social support and psychological distress and associated conditions. In H. B. Kaplan (Ed.), Psychological stress: Trends in theory and research (pp ). New York: Academic Press. Gary F. Koeske, PhD, is Associate Professor, School of Social Work, University of Pittsburgh, 2217 Cathedral of Learning, Pittsburgh, PA Randi Dainwn Koeske, PhD, is Research Consultant and Instructor, Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania. Accepted March 13, 1989 Social Work I May 1989