Interventions: what works., what doesn't?

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1 Occup. Med. Vol. 50, No. 5, pp , 2000 Copyright 2000 Lippincott Williams & Wilkins for SOM Printed in Great Britain. All rights reserved /00 IN-DEPTH REVIEW Interventions: what works., what doesn't? S. Reynolds School of Health Policy and Practice, University of East Anglia, Norwich, UK This review examines the evidence for the effectiveness of occupational stress interventions. Three types of interventions are considered: psychotherapy and counselling services, stress management training, and organizational level interventions. The review concludes that there is good evidence that, for specific mental health problems, formal psychotherapy is effective in terms of reducing individual symptoms. Other forms of intervention have been less well evaluated. The evidence that exists indicates that counselling services and stress management training have modest but short-term effects on individual well-being. Organizational interventions have insignificant effects on individual well-being and on organizational outcomes. Key words: Counselling; mental health; occupational stress; organizational interventions; stress management training; well-being. Occup. Med. Vol. 50, , 2000 INTRODUCTION Increasing awareness of mental health and occupational stress problems amongst employees presents practical demands for employers and occupational health practitioners as they seek to reduce distress in the workforce. This brief review aims to evaluate the evidence for the effectiveness of interventions to reduce distress at work. There are at least two reasons for seeking to reduce distress at work. First, employers may wish to provide optimal working conditions for moral, paternalistic or other socially responsible motives. Second, there is a widespread belief that improving employee well-being will result in better work performance. This latter belief is supported by numerous models and theories of occupational stress and well-being that highlight negative outcomes of occupational stress both for the individual worker, such as health outcomes, and for the organization, such as absence from work, high turnover, low commitment. l ' 2 Assessing the effectiveness of interventions, that is, answering the question, 'Do they work?' depends largely on how 'effectiveness' or 'working' is defined. Research on interventions to reduce occupational stress has tended to examine the effects on individual well- Correspondence to: Shirley Reynolds, School of Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK. Tel: +44 (0) ; fax: +44 (0) ; s.reynolds@uea.ac.uk being and fewer studies have examined the effects of interventions on the organization. This review will highlight both individual outcomes and organizational outcomes where these have been examined. Where possible the studies reviewed in this paper are randomized controlled trials (RCTs) because these are generally accepted to provide the most rigorous evidence of treatment effects. 3 Where RCT evidence is absent, less rigorous research designs are used, such as those for organizational interventions. Research studies evaluating interventions to reduce stress and improve employee well-being have focused on three types of intervention; counselling services, stress management training, and organizational interventions. Counselling services deal with existing problems or those that are developing. Stress management training is provided for workers who are believed to be at risk because their jobs present them with high demands. Stress management training, sometimes referred to as 'pressure management training', therefore, attempts to provide workers with new skills and techniques to manage the demands of their work and thus minimize any negative effects of work on their health and wellbeing. Organizational interventions are the most varied of the three methods. They include attempts to improve workers' control over their jobs, 4 to increase participation in decision making, 5 and to reduce job ambiguity. 6 A fourth group of studies, interventions to prevent the development of post-traumatic stress disorder, are not reviewed in this paper as they have recently been the subject of a comprehensive review. 7

2 316 Occup. Med. Vol. 50, 2000 COUNSELLING AND PSYCHOTHERAPY Workplace counselling is now provided by many organizations. Counselling and psychotherapy services can be provided through external contractors, such as employee assistance programmes, (EAPs), or through specialist internal counsellors. Despite the popularity of workplace counselling services there is little available research on their outcomes. This may be for at least two reasons. First, the sensitive nature of counselling services may deter many counsellors from seeking outcome information. Second, external providers of counselling services are sensitive to disclosing commercially sensitive information such as the effectiveness of the counselling and the satisfaction of the service users. Thus, the data that is available about workplace counselling services is usually restricted to basic information such as service uptake and numbers of counselling sessions provided. Some authors have claimed that there are positive effects on the rates of staff returning to work after sick leave, 8 but these claims are not substantiated by empirical data. There are a small number of relevant studies that examine the effects of counselling for work-related problems and a larger number that examine the effects of psychotherapy for both work-related and mental health problems generally. Counselling and psychotherapy, while related, are distinct activities. Psychotherapy tends to refer to more formalized, defined and theoretically structured interventions designed to deal with specific clinical problems and delivered by members of professional groups such as psychologists or psychiatrists. Counselling interventions tend to be more informal and supportive, they are typically used to help individuals deal with problems of normal life, rather than with specific mental health problems, and are delivered by therapists who often have no specific professional training. The distinction between psychotherapy and counselling has become more blurred, however, as the training and registration of counsellors has become more formalized. Allison et al 9 reported the results of an internal counselling service in the UK Post Office. Counselling reduced absenteeism and clients reported significant improvements in symptoms of anxiety, depression and in self-esteem. There were no changes in job satisfaction or in organizational commitment. Reynolds 10 reported that a brief (three-session) counselling service for local government employees reduced physical symptoms. These positive effects of counselling services are hard to interpret because the study designs were uncontrolled and thus other explanations for these results are possible. Formal RCTs have been used to evaluate the effects of psychotherapy in the treatment of many mental health problems. A series of studies have concluded that psychotherapy is more effective than either no treatment or placebo treatment, and compares favourably with drug treatments for many psychiatric disorders such as depression and anxiety. 11 " 13 Most studies do not specifically focus on employees but one series of studies from Sheffield, UK, has used RCT designs to assess two different forms of psychotherapy, cognitive therapy and psychodynamic therapy, with depressed white collar and managerial employees. Firth and Hardy 14 examined the effects of psychotherapy on 90 depressed employees. There was no difference between the various forms of psychotherapy and participants reported significant improvements in depression and anxiety, and in many aspects of their work environment including job demands, social support at work, variety, and pay. In a subsequent study, Shapiro et al. 15 ' 16 demonstrated that eight sessions of therapy were as effective as 16 for most depressed workers. Only those employees with severe depression benefited from 16 sessions. The extent to which the positive results of RCTs of formal psychotherapy, for clinically significant mental health problems, can be generalized to informal counselling services for workers with less severe problems is unknown. Studies of counselling in primary care setting are equivocal in their findings. 17 However, for workers with specific mental health problems, such as depression or anxiety, the evidence indicates that formal psychotherapy is likely to be helpful. STRESS MANAGEMENT TRAINING Stress management training aims to provide workers with skills and techniques to help them deal with work demands. Techniques taught on stress management training courses include physiological techniques for reducing arousal such as relaxation skills, biofeedback, meditation or breathing exercises, psychological and cognitive techniques of refraining, challenging or replacing negative thoughts or attitudes, interpersonal skills such as assertiveness training or delegation, and work skills such as time management. Stress management training is typically offered in a packaged, pre-programmed format to volunteer employees in groups of between six and 12 participants. Training may be offered over a number of weeks, or intensively over 1 or 2 days. The techniques of stress management training have been shown to be effective in the context of treatment for depression and anxiety but there is less evidence of their effectiveness in helping healthy workers. A number of studies have compared the effects of stress management training with no intervention, or with alternative interventions. For example, Sallis et a/. 18 allocated 76 participants to one of three conditions: stress management training, relaxation training, and an education support group. Participants completed self-report measures and had blood pressure measured before training, again immediately after training and at a 3-month followup. All three interventions resulted in statistically significant reductions in anxiety, depression and hostility, which were maintained at the 3-month follow-up, but without reductions in job satisfaction, work stress or blood pressure. Ganster et al} 9 randomly allocated participants to a stress management training group or a control group. Psychological well-being improved after stress management training but the average change was small in magnitude and the result was not subsequently

3 S. Reynolds: Interventions: what works, what doesn't? 317 replicated. The authors concluded that there were inadequate grounds for recommending the widespread adoption of stress management training. Reynolds et al. 20 examined the outcomes of stress management training in health service workers in terms of selfreported psychological distress (GHQ-12) and job and non-job satisfaction. The results indicated that GHQ scores significantly reduced after training but that job and non-job satisfaction did not change. These studies, and others, indicate that stress management training can improve employees' ratings of their psychological well-being but that the effects are usually small, temporary, and may be obtained using other methods. An important limitation of outcome studies of stress management training is that very few have evaluated organizational level outcomes such as absenteeism, performance or turnover. 21 Where work-related variables are assessed these are usually self-report variables such as work attitudes, or perceptions such as job satisfaction, or perceived work stress, 18 ' 20 rather than tangible behavioural changes. Murphy and Sorenson 22 reported the impact of two forms of stress management training, relaxation and biofeedback, on performance ratings, absenteeism, accidents and work injuries in road maintenance workers. Relaxation training led to reduced absenteeism in the subsequent year. There were no other changes in either of the two treatment groups, and reductions in absence were not observed 18 months after training. The authors concluded that stress management training had little impact on employee behaviours and was probably best used in conjunction with organizational change interventions. This review of stress management training suggests that the apparent benefits of such programmes may be illusory. There appear to be non-specific benefits to subjective well-being in terms of ratings of mood and symptoms but these are also reported after non-specific 'educational groups', and are also rarely sustained to follow-up. Most importantly, few studies have examined the impact of stress management training on organizational outcomes such as absenteeism or performance, and in a context where stress management is believed to convey organizational benefit, this is a clear limitation of research. ORGANIZATIONAL INTERVENTIONS Reviewers have urged research on organizational level interventions for many years. In principle, organizational interventions could attempt to change any feature of work that is believed to contribute to strain. Models of occupational stress have identified potential causes of occupational stress. For example, Karasek 1 identified job demands and decision latitude as key factors in causing job strain. He predicted that jobs with high work demands and low decision latitude led to high strain and to poor mental and physical health in employees. Warr 23 identified nine environmental features that influence mental health and that are present, to varying degrees, at work. These include externally generated goals, environmental clarity, availability of money, physical security, control, skills use and social contact. These different models suggest that there are many possible targets for organizational change. Briner 24 suggested that organizational interventions should be based on a thorough assessment of the organization. This assessment would provide baseline measures of individual and organizational outcomes, and help identify problematic organizational characteristics that are linked to negative outcomes, whether for the individual or the organization. The majority of studies of organizational change suggest that a baseline assessment is not a common prerequisite for developing interventions. In practice, the choice of organizational intervention may be influenced by naturally occurring changes (e.g. job redesign 4 ' 25 ), organizational structure, 5 and theoretical interests, 6 but not the formal organization assessment. Research that evaluates organizational interventions typically compares the target organization, or sector, to a control organization or sector, but randomization to different conditions is rarely possible. Briner and Reynolds 26 reviewed the current evidence for organizational level stress interventions. They concluded that in most studies the effects of the interventions were minimal and had mixed positive and negative effects. For example, in a job redesign study, Wall et al. A reported an increase in intrinsic job satisfaction, no effect on motivation, commitment, mental health or performance, and an increase in turnover and disciplinary dismissals. Similarly, Cordery et al., 25 after a job redesign exercise, reported increases in job satisfaction and job commitment, no changes in trust in management and increases in absenteeism and turnover. Job redesign presents significant disruption to an organization. Several studies have examined the effects of social interventions that seek to change aspects of the work but present less disruption to the organization. Schaubroeck et al. 6 reduced role ambiguity at work but this had no effect on employees' symptoms or on absence from work. Heaney et al. 5 attempted to increase the participation of workers in organizational problem solving. The effects of the intervention were negative; there were no changes in employee well-being or in the social environment at work, and supervisor emotional support and participative climate both decreased. Overall, studies of organizational change interventions indicate that they are not effective in improving employee well-being or in improving organizational outcomes. Reynolds 10 reported a comparative study of a counselling service and organizational change intervention. One year after the introduction of the intervention, levels of physical symptoms reduced in the area that received the counselling service and increased in the areas receiving the organizational intervention and in a control area. Psychological well-being and absence from work did not change in any area over the intervention or follow-up period. Employees made strongly positive comments about the counselling service and made mixed and negative comments about the organizational intervention.

4 318 Occup. Med. Vol. 50, 2000 Table 1. Summary of designs and outcomes of stress management interventions Intervention Design Organizational well-being Organizational well-being Individual counselling (worksite) Naturalistic design Substantial improvement Not generally assessed Individual counselling (primary care) Minimal improvement Not generally assessed Psychotherapy for mental health problems Substantial improvement, sustained at follow-up Not generally assessed but some evidence of improved work perceptions Stress management training Modest improvement, short-term No evidence Organizational interventions Quasi-experimental design Small or no improvements Small or no improvements CONCLUSION The results of this review are summarized in Table 1. Research evidence suggests that the optimal psychological treatment for mental health problems in employees is an established, formal method of psychotherapy, such as cognitive behaviour therapy. The evidence for the use of employee counselling services is not well established and similar studies in primary care have found small effects. However, counselling services in primary care settings and in the workplace 10 appear to be very popular and employers and occupational health services may be encouraged by employees to provide these. Stress management training results in small improvements in employees' psychological well-being but these improvements are short-term and may not be specific to stress management training. Organizational level interventions have not been demonstrated to be of significant benefit to employees or to organizations. There is a strong need for controlled trials of worksite counselling services and for the further development of organizational level stress interventions. Therefore, although theoretical work and common sense suggests that changing unpleasant and noxious work environments will be of benefit both to employees and to their organizations, this cannot be supported by the empirical research that is currently available. REFERENCES 1. Karasek R. Job demands, job decision latitude and mental strain: Implications for job redesign. Administrative Science Quarterly 1979; 24: Cooper CL, Marshall J. Understanding Executive Stress. London: Macmillan, Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine. New York: Churchill Livingstone Wall TD, Kemp NJ, Jackson PR, Clegg CW. Outcomes of autonomous workgroups: A long-term field experiment. Academy of Management Journal 1986; 29: Heaney CA, Israel BA, Schurman SJ, Baker EA, House JS, Hugentobler M. Industrial relations, worksite stress reduction and employee well-being: A participatory action research investigation. J Organizational Behav 1993; 14: Schaubroeck J, Ganster DC, Sime WE, Ditman D. A field experiment testing supervisory role clarification. Personnel Psychology 1993; 46: Wesseley S, Rose S, Bisson JA. A systematic review of brief psychological interventions (debriefing) for the treatment of immediate trauma related symptoms and the prevention of post traumatic stress disorder. Cochrane Review Nov. 97. Oxford: The Cochrane Library. 8. Trice HM, Beyer JM. Work-related outcomes of the constructive - confrontation strategy in a job-based alcoholism program. J Studies on Alcohol 1984; 45: Allison T, Cooper CL, Reynolds P. Stress counselling in the workplace: The Post Office experience. The Psychologist 1989; 2: Reynolds S. Psychological well-being at work: Is prevention better than cure? J Psychosom Res 1997; 43: Shapiro DA, Shapiro D. Meta-analysis of compariative psychotherapy outcome studies: a replication and a refinement. Psychobgical Bulletin 1982; 92: Wampold BE, Mondin GW, Moody M, Strick F, Benson K, Ahn H. A meta-analysis of bona fide psychotherapies: Empirically 'all must have prizes'. Psychological Bulletin 1997; 122: Gloaguen V, Cottraux J, Cucherat M, et aj. A meta-analysis of the effects of cognitive therapy in depressed patients. J Affective Disorders 1998; 49: Firth-Cozens JA, Hardy GE. Occupational stress, clinical treatment and changes in job perceptions. J Occup Organizational Psychol 1992; 65: Shapiro DA, Barkham M, Rees A, Hardy GE, Reynolds S, Startup M. Effects of treatment duration and severity of depression on the effectiveness of cognitive - behavioural and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol 1994; 62: Shapiro DA, Rees A, Barkham M, Hardy GE, Reynolds S. Effects of treatment duration and severity of depression on the maintenance of gains following cognitive-behavioural and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol 1995; 63: Friedli K, King MB, Lloyd M, Horder J. Randomised controlled assessment of non-directive psychotherapy versus routine general practitioner care. Lancet 1997; 350: Sallis JF, Trevorrow TR, Johnson CC, Hovell MF, Kaplan RM. Worksite stress management: A comparison of programs. Psychology and Health 1987; 1:

5 S. Reynolds: Interventions: what works, what doesn't? Ganster DC, Mayes BT, Sime WE, Tharp GD. Managing organizational stress: A field experiment. J Appl Psychol 1982; 67: Reynolds S, Taylor E, Shapiro DA. Session impact and outcome in stress management training. J Community Appl Soc Psychol 1993; 3: Ivancevich JM, Matteson MT, Freedman SM, Phillips JS. Worksite stress management interventions. American Psychologist 1990; 45: Murphy LR, Sorenson S. Employee behaviors before and after stress management. J Organizational Behav 1988; 9: Warr PB. Work, unemployment and mental health. Oxford: Clarendon Press Briner RB. Improving stress assessment: towards an evidence-based approach to organizational stress interventions. JPsychosom Res 1997; 43: Cordery JL, Mueller WS, Smith LM. Attitudinal and behavioural effects of autonomous group working: A longitudinal field study. Academy of Management Journal 1991; 34: Briner RB, Reynolds S. The costs, benefits, and limitations of organisational level stress interventions. J Organizational Behav 1999; 20: