Getting to Know You: Occupational Health Researchers Investigate Employee Assistance Professionals’ Approaches to Workplace Stress

Abstract

Workplace stress is strongly associated with health problems, including cardiovascular disease. The occupational health field is developing partnerships with a variety of health professions to prevent and address job stress at the organizational level. A review of literature for and about employee assistance professionals was conducted to explore their perspectives on these issues. Results show high awareness regarding the health effects of job stress and a wide range of approaches to address this problem. EAPs appear to be a potential strong partner in efforts to prevent workplace stress, but face obstacles to intervening at the level of the work environment.

Work-related stress, work organization factors that lead to stress and associated cardiovascular and other diseases (such as depression, anxiety, cognitive impairments, and substance abuse), are increasingly urgent topics in occupational health. Researchers in these areas from the Center for the Promotion of Health in the New England Workplace (CPH-NEW) recognize that employee assistance (EA) professionals are central actors in addressing employee stress, yet the EA profession is largely unfamiliar to occupational health practitioners. To approach EA professionals respectfully as potential partners in education and practice, we conducted a literature review to learn about this field’s perspectives on job stress.

BACKGROUND

The National Institute for Occupational Safety and Health (NIOSH; 2009) placed Work Organization and Stress-Related Disorders among its main priorities. NIOSH explained, "Job stress results when there is a poor match between job demands and the capabilities, resources, or needs of workers" and that this is a highly prevalent problem, with an estimated one third of workers reporting high levels of job stress.

NIOSH (2009) described "work organization" as referring "to the nature of the work process (the way jobs are designed and performed) and to the organizational practices (e.g., management and production methods and accompanying human resource policies) that influence the design of jobs." Recent trends in work organization, such as downsizing, restructuring, outsourcing, and lean production, may be related to increased job stress.

Since 2006, NIOSH has funded CPH-NEW, a partnership between researchers at the University of Massachusetts Lowell and the University of Connecticut. CPH-NEW (2009) aims to evaluate models for integrating workplace health promotion with occupational ergonomic and mental health interventions. One CPH-NEW project, "Stress@Work," is an education, translation, communication, and dissemination effort aimed at various categories of health professionals. This initiative is developing curricula and assisting in training on health promotion-occupational health and safety integration and the relationship between work-related stress and the development of heart disease and stroke. CPH-NEW builds on the work of researchers who have emphasized organizational-level change to reduce sources of workplace stress, rather than individual-level change to help people cope with stress (Karasek & Theorell, 1992; LaMontagne, Keegel, Louie, Ostry, & Landsbergis, 2007; Landsbergis, 2003).

CPH-NEW advisors identified EA professionals as a potential category of participants given their responsibilities to employee health. The EA field clearly addresses organizational-level interventions: the "EAP core technology" described by the Employee Assistance Professional Association (International Employee Assistance Professionals Association, 2009) includes "Consultation with, training of, and assistance to work organization leadership … seeking to … enhance the work environment" and stated that "Employee Assistance Programs (EAPs) serve organizations and their employees in multiple ways, ranging from consultation at the strategic level about issues with organization-wide implications to individual assistance to employees and family members experiencing personal difficulties."

To better understand EA professionals’ current perspectives on, and approaches to, workplace stress, we conducted a literature review to address these questions:

1. Does literature for and about EA professionals discuss job stress as a concern addressed in EA practice? If so, is job stress identified as a cause of cardiovascular disease (CVD)?

2. What types of causes of job stress are described, and to what degree do these include environmental or organizational causes of stress versus causes rooted in individual employees?

3. What types of interventions are proposed to prevent, reduce, or control job stress, and specifically, how are interventions to change environmental or organizational factors described versus those aimed at changing individual employees?

METHOD

Two types of literature were examined: literature for EA professionals and literature about Employee Assistance Programs (EAPs). Interviews with EA professionals consistently suggested that the main publications read by their colleagues were the Journal of Workplace Behavioral Health (formerly Employee Assistance Quarterly) and the Journal of Employee Assistance. For literature about EAPs, databases indexing peer-reviewed literature, trade journals and periodicals related to health, employment, and psychology were searched: Academic Search Premier, Business Source Premier, CINAHL, PubMed, and PsychInfo. For both types of literature, search terms included EAP and employee assistance in combination with anxiety, cardiovascular disease, demand control, effort reward, flex time, flexibility, heart disease, job content questionnaire, job strain, job stress, obesity, occupational health, stroke prevention, and work organization. Articles cited in the databases were included regardless of publication date. Because different journals are indexed in these databases beginning in different years, no consistent starting date was used as an inclusion criterion. The earliest article found to be relevant was published in 1982, but it is possible that other potentially relevant articles from the 1980s were not identified because the journals where they were published were not indexed until later dates. The review was concluded in 2008. Articles identified were examined by investigators for substantial relevance to the research questions. One major category not directly relevant, critical incident stress management, was excluded.

At the suggestion of a reviewer, we examined the nationality and specialties of the lead authors to explore any apparent connections between these factors and the types of ideas they presented. Of 103 articles, we were able to identify indications of the first author’s country of residence for 82. Countries represented by more than five authors each were the United States, United Kingdom, Canada, and Australia. Nine authors were identified as psychologists and 13 as social workers either by their listed qualifications corresponding to one of those fields (e.g., psychologist, LCSW) or by their affiliation with departments of psychology or social work. To make these determinations we used only information printed on the article and did not perform additional biographical research.

RESULTS

Themes in literature for and about EAPs and EA professionals were similar, and so results from both categories were combined. Responses to the three main study questions generally broke down into the following categories:

• 1.Literature that names stress as an issue of concern for EAPs to address.
  • 1.a.Literature that cites an association between job stress and CVD.
• 2.Literature that cites only individual-level causes of stress versus literature that names some environmental or organizational causes of stress.
• 3.a.Literature that cites organizational causes of stress but only individual-level solutions.
• 3.b.Literature that cites organizational causes and organizational-level interventions.
  • 3.b.i.Literature that cites organizational-level interventions but states that EAPs focus only on individual-level interventions.
  • 3.b.ii.

    Literature that cites organizational-level interventions and states that EAPs do, can, or should include organizational interventions.

1. Literature that Names Stress as an Issue of Concern for EA Programs to Address

Several articles for EA professionals and about EAPs discussed job stress as a concern addressed in EA practice. One aspect of EAPs is that they provide counseling and information on a myriad of personal issues including stress ("Employers are Split," 2006; Golding, 2007; MacDonald & Well, 1995; Rafter, 2004; Robertson, 2006; Tiffany, Tiffany, Sinnett, & Sinnett, 1992), EAPs help people cope with stress (“Employers Taking Proactive Approach to EAPs,” 2005), or reducing stress is an important factor in improving productivity and job satisfaction (MacDonald & MacIntyre, 1997).

Some went further to present job stress as one of the most common problems or a primary area for EA professionals (Rich, 1987; Van Den Bergh, 2000; Yamatani, Santangelo, Maue, & Heath, 1999), a key reason for employers to have EAPs (Lee, 2005; Rich, 1987), or the leading reason that employees contacted a particular EAP (Masi & Jacobson, 2003). In fact, some have even suggested that growth in EAPs may be largely due to employer recognition of stress as a workplace phenomenon (Kirk & Brown, 2003).

A few articles stated that addressing job stress is actually included in the definition of EAPs (Haaz, Maynard, Petrica, & Williams, 2003; Tiffany et al., 1992). Merrick (2002) wrote, "An EAP is a work-focused programme designed to help employees cope with stress affecting their work" (p. 43), whereas Berridge and Cooper (1993) started from the assumption that addressing stress is obviously part of the EAP function.

Job stress has been identified as an EAP issue in the context of traditional EAP concerns such as alcoholism, drug abuse, depression, absenteeism, and productivity (Etzel, Lantz, & Yura, 1995; Haaz et al., 2003; Masi & Jacobson, 2003; Ramanathan, 1995; von Freymann, 2002). Several articles stated that expansion from a sole focus on substance abuse to issues including job stress was part of the evolution of the EAP field especially during the 1970s and 1980s (Kirk & Brown, 2003; Murphy, 1995). Some authors also connected job stress to occupational safety, arguing that high levels of stress can lead to accidents (Ramanathan, 1995) or that stress can lead to depression whereas coworkers’ reactions to a worker’s depression can in turn increase his stress, resulting in increased accidents (Chima, 2004).

1.a. Literature that cites an association between job stress and CVD

Several articles for EA professionals and about EAPs named stress as a contributor to CVD. One review of screening and management of CVD caused by job stress discussed the roles of EAPs (Nowack, 2000). In fact, some suggested that concern about CVD could be a principal reason that managers want to address stress (Bull, 1997). Many presented this link to overall CVD (Bhagat, Steverson, & Segovis, 2007; Dolan, 1994; Ramanathan, 1990, 1995; Robertson, 2006; Shain, 1996). Others specified forms of CVD such as coronary heart disease (Chima, 2004; Clarke & Cooper, 2000; Fielding, 1989; McHugh & Brennan, 1992), heart attack (Kedidjian, 1995), high ambulatory blood pressure and structural heart changes (Felton, 1998), and high or unstable blood pressure or high cholesterol (Colligan & Higgins, 2005; Dolan, 1994; Giga, Cooper, & Faragher, 2003; Nel & Spies, 2006). At least one quoted a specific study’s findings on increased risks of stroke-and heart-related disease among men and women with high stress (Lee, 2005).

Not all articles supported an association between job stress and CVD. At least one author challenged this association, skeptically mentioning CVD as one of a long list of conditions claimed to be associated with job stress (Reynolds & Briner, 1994).

2. Literature that Cites Only Individual-Level Causes of Stress Versus Literature that Names Some Environmental or Organizational Causes of Stress

Some articles for EA professionals and about EAPs have described stress as resulting from characteristics, activities, or personal lives of individuals (MacDonald & MacIntyre, 1997; Mendez & Barlow, 2002) and presented only individual-oriented wellness, "amelioration" approaches to addressing it (Lee, 2005). Researchers who investigated causes of stress affecting a population of nurses to develop recommendations for their EAPs actually excluded measurements of stress related to work. Instead, they focused on family, social roles, and individual issues (Howell & Fiene, 2005).

Several articles published by U.S. authors in the 1980s presented this perspective. One article stated that a certain proportion of employees at any given workplace are expected to be troubled, implying that working environments are not a significant contributor. In this view, EAPs were seen only to help employees manage stress (Fitzerald, Hammond, & Harder, 1989). Others stated that EAPs can help employees through education, counseling, and referrals, and by helping them to cope with relocation stress (Anderson & Stark, 1988; Gaylord & Symons, 1986).

By contrast, a large body of literature for and about EAPs recognized organizational or environmental causes of stress. This included some articles from the 1980s, but mostly from the 1990s through 2008 (see below). They divided into those that, nonetheless, discussed only individual-focused approaches to intervention, and those that included discussion of interventions that focus on the organization or work environment. These two categories are described in the following section.

3.a. Literature that Cites Organizational Causes of Stress but Only Individual-Level Solutions

Several articles for and about EAPs have recognized work as an important contributor to stress but offered only individual-oriented solutions. EAPs use assessment, education, and referrals to help people cope with job-related and personal stress (Philips & Mushunski, 1992), because "how we manage stress" is a key to surviving at work (McNally, 1999). Recupero (2003) referred to stress created by the work environment and responded with training in personal skills to recognize and manage stress, such as relaxation training.

The article "De-stressing the Workforce" (rather than "the workplace") described pressure at work as a source of stress but presented all individual solutions, including support and counseling provided by EAPs (Cuthell, 2004). Csiernik and Adams (2002) took organizational sources of stress for granted as an inherent aspect of work while examining spirituality and the EAP’s role in responding to stress.

Nel and Spies (2006), Bhagat et al. (2007), and Nakao, Nishikitani, Shima, and Yano (2007) presented extensive discussions of environmental causes of stress including globalization, restructuring, and overwork. Nakao et al. even used Karasek’s Job Content Questionnaire, a tool used to assess work organization (Karasek, Brisson & Amick, 1998). Bhagat et al., however, defined EAPs’ roles only as helping people cope, and the EAP interventions studied by Nakao et al. consisted of individual counseling, education, and referral to psychiatric services. Nel and Spies focused mainly on individual-oriented techniques such as play therapy and the relaxation response. Fronstin (1996) suggested that EAPs offer counseling to help people manage stress and cope with the effects of company downsizing.

Articles about certain types of workplaces described organizational causes of stress in hospitals such as changes in roles, 24-hour commitment, and role tension. EAPs’ roles in this situation are counseling, referral to treatment, and motivation (Howard & Szczerbacki, 1988). An article about the FBI took for granted that stress is part of agents’ jobs involving violent incidents and death. It listed EAPs along with other programs for coping with this stress but did not mention preventive changes in work organization (Sheehan, 1999). Rich (1987) described aspects of the press industry that make it stressful but discussed EAPs adopted in response to this stress as providing counseling and referrals. One article discussed organizational causes of stress but listed EAPs as a method for addressing this problem by helping individual workers figure out how to solve their own problems (Kedidjian, 1995).

A few articles presented a middle ground between interventions focused on the individual and those focused on the environment. They recognized organizational and environmental causes of stress and discussed interventions that do not attempt to address these root causes but do go beyond individual counseling. These approaches provide organizational support for coping with or adapting to stressful work environments. Some of these authors named organizational factors associated with stress including economic changes, work hours, staffing, scheduling, time pressures, and work-family balance. They described EAPs preparing more supportive supervisors and also helping people with family and financial issues (Noelker, Ejaz, Menne, & Jones, 2006), including locating practical information on financial, real estate, and family services (Bromage, 2000; MacAlpine, 2003). Nel and Spies (2006) mentioned on-site training in people skills, conflict management, and other relevant skills to help employees in stressful work environments.

El-Bassel, Guterman, Bargal, and Su (1998) and Pierre (1986) described the roles of EAPs in addressing workplace stress as building strong social support at the workplace to "short-circuit" effects of stress. Approaches included teaching interpersonal skills, creating formal support networks, encouraging workers to seek people to talk with, promoting the use of resources such as EAPs, and creating after-care systems for employees who have experienced personal crises.

Sprang and Secret (1999) described jobs that are "demanding, female-oriented, low-paying and emotionally and physically depleting" and therefore stressful. Employer or coworker insensitivity or abusive attitudes toward the distressed employee exacerbate the problem. EAPs can help support and provide information to distressed employees and help employers identify and respond to employees’ distress.

3.b. Literature that Cites Organizational Causes and Organizational-Level Interventions

Many articles (cited in the subsections below) described organizational-focused interventions as well as organizational causes of stress. Some cited NIOSH (2009) or Karasek (Colligan & Higgins, 2005; Nissly & Mennen, 2002), indicating their familiarity with work organization approaches from the field of occupational health. These are divided between those that described the particular role of EAPs, however, as mainly focused on the individual, and those that stated that EAPs do, or should, intervene at the organizational level as well. (A few articles discussed organizational causes of stress, organizational interventions, and EAPs as a method for addressing this problem but did not specify their role; Blostein, Eldridge, Kilty, & Richardson, 1985; Gibson, 1993; Moore, 2001.)

3.b.i. Literature that cites organizational-level interventions but states that EAPs focus only on individual-level interventions

At least two articles for EA professionals (Macdonald & MacIntyre, 1997; Reynolds & Briner, 1994) and many more about EAPs (cited in the following paragraphs) discuss organizational-level interventions while explaining that EAPs focus on the level of the individual. Some argued that organizational interventions are unproven or ineffective and that EAPs can therefore be most effective by focusing on the individual; some that organizational interventions are potentially effective but infeasible or uncommon so that helping people cope is a leading priority; and others that organizational interventions are crucial but best performed by other stakeholders, with EAPs complementing organizational change with individual services.

A brief trade journal article ("Rise in Stress Boosts EAPs," 2003) falls on the first end of this spectrum, recognizing EAPs specifically as a response to work-related stress but contending that workplace contributions to stress may be overstated. Reynolds and Briner (1994) also argued that organizational interventions are uncommon and unproven. Instead, these authors emphasized employee perceptions of work environment problems. The most important organizational intervention is therefore addressing obstacles that can prevent people from getting individual help in managing their perceptions. MacDonald and MacIntyre (1997) also found that people’s affective reactions to their jobs are more important than actual job characteristics.

Berridge (1999; Berridge & Cooper, 1993) reviewed a detailed range of work organization changes but explained that barriers to organizational responses would suggest that authors still refer mostly to interventions on the individual employee level rather than an organization change response.

Certain barriers to organizational interventions have been described in several sources. One such barrier has been the need to protect confidentiality. Some authors proposed that aggregate data on use of EAP services should be used to help employers or unions target organizational interventions but warned that sharing data from small companies or departments could allow managers to identify the employees who have used EAP services. The need to protect confidentiality can also prevent EAPs from taking action to address workplace problems that affect particular employees. These issues limit EAPs mostly to individual advice, information, counseling, and referrals, and potentially to training managers to identify and manage stress (Golding, 2007; Green, 1997).

Another frequently cited issue (Beidel, 2005; Bento, 1997; Kirk & Brown, 2003; Ramanathan, 1995; Shain, 1996) is the contracting out of EAP services. Nissly and Mennen (2002) argued that this mostly limits them to individual-focused interventions. The article therefore focuses on EAP-led interventions such as relaxation skills, meditation, biofeedback, fitness, and cognitive restructuring combinations.

A number of other articles discussed organizational interventions including improvements in workload, autonomy, schedule flexibility, and family support services but describe EAPs as working on the individual level (Barrett, 2005; Briner, 2000; Collins & Killough, 1989; Dolan, 1994; Fielding, 1989; Jaffe, Scott, & Orioli, 1986; Smith, 1999). For Colligan and Higgins (2005), EAPs focus on employees’ perceptions of stressors and help them to cope, relieve the effects of stress, take responsibility for their stress-related symptoms, and work through issues. Orpen (1984) recommended that EAPs help individuals with stress and refer to psychologists who offer relaxation training. Masi and Jacobson (2003) assessed EAP effectiveness by asking clients how their EAP addressed "their ability to manage work stress."Felton (1998) recommended organizational interventions but suggested that EAPs can help individuals when personal problems further contribute to job stress. A review of worksite depression management mentioned stress as a contributor to depression and workplace issues such as unresolved conflict as contributing to stress but presented the main role of EAPs as helping depressed employees obtain treatment (Steffick, Fortney, Smith, & Pyne, 2006).

Some articles have stated clearly that EAPs’ individual-focused approaches are not sufficient to address stress, and that individual counseling must be complemented by a range of organizational interventions to address environmental factors, technology, organizational culture, job design, management style, work load, and work hours ("Causes of Workplace Stress," 1997). Giga et al. (2003) stated "Individual person-directed stress management programs that attempt to empower workers to deal with demanding situations by developing their own coping skills and abilities are unlikely to maintain employee health and well-being in the long-term without procedures in place within organizations for reducing or preventing environmental stressors" (p. 282).

3.b.ii. Literature that cites organizational-level interventions and states that EAPs do, can, or should include organizational interventions

A body of literature not only recognized organizational-level interventions for work stress, but also, unlike the articles described in the previous section, argued that EAP practice is adopting or needs to adopt an organizational focus. Two key articles, one for EA professionals (Shain, 1996) and one about EAPs (Murphy, 1995), provided extensive historical arguments directly addressing the need for EAPs to adopt an organizational focus. Other articles that also discussed or expanded on some of the themes developed by Shain or Murphy are then reviewed below.

The article "Employee Assistance and Organizational Change: New Evidence, New Challenges, New Standards?" (Shain, 1996) proposed that the idea of EAPs as organizational change agents "has been intimated or discussed in the EAP literature and at national EAP conferences for at least the past fifteen years. In the case of industrial/occupational social work, there has been a history of efforts to influence the workplace environments from which clinical cases have emerged for treatment" (pp. 1–2). This author listed references starting from 1981 that addressed ways for EAPs to affect the organization and management policy.

With regard to workplace stress, Shain (1996) argued that EAPs need to understand recent scientific evidence about the connections between psychosocial hazards and health. He discussed and illustrated Karasek’s demand-control model (Karasek & Theorell, 1992) but also listed important psychosocial hazards in lay terms (e.g., too much time pressure, duties that conflict with one another, too little employee influence over what is done, unfair treatment). This article connected job stress to traditional EAP concerns by showing that substance abuse potentiates, and home stress exacerbates, the effects of job stress. Although EAPs probably recognize these connections intuitively, they can make the case to management more strongly using research evidence. The article proposed that providers conduct pattern searches for problems that might result from psychosocial hazards, then provide feedback to EAP Committees or Coordinators, who can use this as input to management (Shain, 1996).

This strategy involves forming strategic alliances with occupational safety and health and other health professionals, for example, "One can conceive of a ‘working environment committee’ struck from the memberships of EAP, OHS and Health Promotion constituencies" (Shain, 1996, p. 8). Members could then make recommendations to management on topics such as communication, division of labor, supervisory practices, sensitivity to needs of minority groups, effectiveness of antidiscrimination and antiharassment policies, fairness of policies about space, schedules, shifts, physical work environments, and supportiveness (Shain, 1996).

Shain (1996) discussed the issue of internal versus external providers: some feel that internal providers may not be able to play the role of organizational change agent because they are controlled by management, but in fact external providers can be fired. "This vulnerability of E.A. providers points very clearly, in the view of this writer, to the need for a standard of practice in the field that will make it difficult if not impossible to find a reputable practitioner of employee assistance who will agree to forego the role of organizational critic" (p. 10). The author posited a need for leadership in the EA profession to educate about and promote this kind of organizational change.

The article "Managing Job Stress" (Murphy, 1995) presented the full occupational health model of job stress as a framework to describe typical EAP practice: "Historically, EAPs have focused on characteristics of the employee, not characteristics of the job/organization, which may be causing employee stress. This focus on the individual is evident in the types of stress management programmes offered at the workplace. The most common stress management programmes are those which educate employees about the nature of stress, and change some characteristic(s) of the individual, not the organization" (p. 44). "EAP counselors have not been trained in organizational behaviour, and may not appreciate the effects of job/task factors and management practices on employee health" (p. 44).

Murphy (1995) argued that EAPs provide very limited feedback to management, and rarely regarding characteristics of the job or organization. Human resources (HR) management groups, by contrast, have expertise in job factors and management practices but focus on performance, not health. Murphy described NIOSH support for the formation of an HR-EAP collaboration at a large U.S. manufacturing firm that added job stress questions to their climate questionnaire to plan a worksite intervention. Murphy proposed that EAPs focus on interpersonal relationships as well as employee personal characteristics, whereas the HR management could focus on organizational culture/climate, job/task features, and organizational practices.

Themes discussed by Shain (1996) and Murphy (1995) were further addressed in the articles described in the following sections.

EAPs AS PART OF INTEGRATED TEAMS AND A HOLISTIC APPROACH

Shain’s (1996) ideas about "working environment committees" and Murphy’s about HR-EAP collaboration have been echoed by others, before and after their articles. Lewis (1989) described workplace stress in the context of occupational health to be addressed by EA professionals called occupational social workers. These social workers should be part of an occupational health clinical team, with medical and industrial hygiene professionals and organized labor. Social workers’ holistic, integrative approach can address the psychological effects of chemical/physical workplace hazards, and interactions among physical/chemical hazards, work organization and family issues. Csiernik (2005) has discussed this approach in depth. Eischen, Grossmeier, and Gold (2005) also proposed that EAPs lead multidisciplinary intervention teams to prevent workplace violence.

Stennett-Brewer (1987) and Kirk and Brown (2003) described EAPs’ roles in complementing HR. They wrote that EAPs should perform organizational stress diagnoses to identify areas of organizational dysfunction. EAPs can take actions to address underlying organizational problems, for example, by facilitating problem-solving meetings or consulting for supervisors stressed about difficulties in their roles. Their work should consider organizational factors including effective communication, adequate training and feedback, clear role expectation, and supervisor support (Stennett-Brewer).

Kirk and Brown (2003) argued that EAP researchers have long recognized a need to address stressful work environments but agreed with Murphy (1995) that EA professionals are not usually trained in organizational dynamics or managing the dual-client situation. Therefore, EAPs should partner with other HR divisions. The article referred to ongoing efforts to define each HR division’s area and suggestions to rebrand EAPs as Corporate Assistance Programs to better address the individual-organizational interface.

INTERNAL VERSUS EXTERNAL EAPs

The issue described by Shain (1996) of EAPs internal to the employer versus those contracted externally arose in several articles. Kirk and Brown (2003) described "slight differences between programs provided by internal and external EAPs" (p. 139) with internal providers reporting more frequent organizational-level interventions and external providers more often addressing family, medical, and legal problems. Ramanathan (1995) argued that internal EAPs are better situated to intervene in the work environment. Bento (1997) also supported internal EAPs, contending that they are more likely to be successful if they are seen as integral to the HR efforts of the organization, allowing them to propose changes in job design, career planning, and training. Beidel (2005) argued that an internal EAP that is truly integrated into an organization can help mitigate the stressful effects of major change initiatives by being involved directly in planning and decision making and provides a series of recommendations for EAP-organizational integration.

Csiernik (1999) conducted a review of literature comparing internal and external EAPs, augmenting previous findings with his own experience. He identified a number of advantages and disadvantages of both types of programs. Most relevant to this discussion, he confirmed that internal programs are better positioned to understand and respond to workplace dynamics and have a more complete understanding of workplace policies and procedures.

Several authors raised territorial issues for EAPs in this context. Kirk and Brown (2003) warned that HR may see EAPs’ organizational-focused efforts as incursions into their territory. Bento (1997) explained "if the people who make decisions in these areas resent the EAP’s intrusion in their territory, the results may be personally frustrating to the EAP staff and politically dangerous to the EAP" (p. 87). In addition, the types of organizations that put demands on their employees leading to their need for EAP counseling are presumably the same types that will resist providing the EAP with the resources and flexibility to make needed changes. Similarly, Stennett-Brewer (1987) stated "Any stronger attempts by the EAP to affect organizational dynamics on an uninvited basis will risk perception by management that the EAP is an intrusive troublemaker" (p. 26).

EAPs IN A HISTORIC TRAJECTORY TOWARD AN ORGANIZATIONAL FOCUS

Like Shain (1996), many articles cited changes in the EAP field over previous decades, especially its overall growth and expansion from its original alcoholism focus and the medical model of treatment to a broad range of issues. As far back as 1982, Hayes and O’Connor (1982) proposed EAP involvement in supervisor training on roles and skills to address job-related stress related to role ambiguity, isolation, unclear lines of authority, and other organizational issues. Quoting an earlier social work analysis of M. N. Osawa, Berridge and Cooper (1993) described EAP history from Stage I of EAPs just identifying and referring problem employees through Stage III: organizational interventions and recognizing systematic cause of problems and Stage IV: serving mainly as organizational development consultant to management.

Googins and Davidson (1993) and Midgely (1997) also wrote that EAPs were evolving toward treating the organizations, rather than individual employees, as their clients. They were increasingly addressing work practices and the work environment to alleviate stress. By the early 1990s EAPs started to address organizational sources of stress, some formally changing into Organizational Assistance Programs (Berridge, 1999).

EAP roles considered new for the early 1990s included feeding data back to the organization, convening actors to make policy decisions and strategize (e.g., about provision of child care, work–family policies), influencing policy directly, facilitating collaboration, framing issues, and helping supervisors manage problems brought on by financial downturns or changes in the work environment (Googins & Davidson, 1993). Midgely (1997) reported that some EAPs were starting to advise companies on ways to change their work practices to reduce stress.

Van Den Bergh (2000) suggested that much literature in the 1990s discussed changes in the traditional EAP paradigm of helping the "troubled employee" through referrals and treatment. This article discussed an ecological approach, or goodness of fit between worker and environment, recommending the development of programs and policies to build a caring community at the workplace.

Ethical Conflicts and Contradictions

Problems with the traditional EAP framework described by Shain (1996) and Murphy (1995) were explored more intensively by authors emphasizing the costs and conflicts of this approach. Some authors point out EAPs can be caught in conflict between their roles serving the employer and serving the individual employee (Greenwood, 1997), "lying as they do in ‘disputed territory’ between the professional therapists, the personnel managers and the company financial officers" (Berridge & Cooper, 1996, p. 93). Berridge and Cooper (1993) reviewed discussions on inherent contradictions between EAPs’ role to support profitability and productivity of the company, but also the well-being of employees. EAPs have been accused of being another tool to control deviance and bring employees more fully into the company program, as well as to protect the employer from lawsuits, workers’ compensation claims, and conflict with unions. As one illustration, Attridge (2005) explained that EAPs traditionally help companies plan organizational change, for example, downsizing, to reduce costs. Several sources have mentioned EAPs as employer methods to defend themselves against stress-related claims (Dolan, 1994; Greenwood, 1997; Keefe, 2005; “Stress Risk Assessments and EAPs,” 2003) or prevent absenteeism (Von Freymann, 2002). Fitzgerald et al. (1989) even argued that it is not in EAPs’ interest to address underlying causes of problems.

Some authors have presented EAPs’ individual-oriented approaches to work stress as actually exacerbating the problem rather than helping to address it. Arthur (2000) argued that EAPs are largely ineffective because they by design do not attempt to prevent or reduce workplace stress, but operate on the assumption that workplaces will not change, and therefore only attempt to reduce the effects of stress by helping individuals to adapt. Another article argued that EAPs can in fact shield employers from knowledge of causes of stress due to confidentiality. EAPs are contrasted with stress risk assessments, which tackle root causes of occupational stress. This article celebrates a model program that, unlike EAPs, uses a counseling service that can "act as an advocate or link with the organization, and to make direct and immediate changes in the workplace, in response to individual needs" (“Stress Risk Assessments and EAPs,” 2003, p. 43).

A case study of a hospital (Trubshaw & Dollard, 2001) found that stress for nursing staff resulted from work speed-up, increased paperwork, reduced staff, and possibly less human contact, and that EAPs formed part of the management approach to blaming individual workers instead. These authors argued that employing EAPs is a Band-Aid that enables people to remain at work longer under stressful conditions rather than fixing the underlying problems by improving communication and addressing workload and work pace issues. Worse, when one hospital studied had a 1000% increase over 10 years in numbers of employees attending staff counseling services during a speed-up phase, management responded by more stringently investigating overtime and sick leave claims and instituting more authoritarian policies rather than changing the work environment. Data from the counseling service were not even fed back to improve organizational practice and job design. "The naming of a ‘social problem rather than a ‘work environment problem’ as a reason for use of the service further reinforces the notion of individuals being responsible for their own health states and reactions, rather than the responsibility of the hospital management to reengineer the nurse work environment" (p. 443).

Berridge (1999) summarized EAP practice within a societal context that promotes work stress:

In the 1980s in Britain, many early programs were of the "Band-Aid" type—imposed by a concerned organization on troubled employees to treat the immediate symptoms with little concern for the underlying causes. Where these causes lay within the organization, a fundamental cultural change was often required …. Thus employee counselling represented a tertiary-level intervention aimed at treating employee clients as the inevitable victims of organizational Darwinism in an enterprise culture promoted by Thatcherism. (p. 264)

Bull (1997) repeated the theme of EAPs "as psychological band-aids, resulting in a wounded workforce which is unable to give of its best" (p. 36). Many U.S. EAPs, in particular, medicalize stress: “Employees are ill and have to be ‘treated’” (p. 37). Counseling could actually undermine trade union or occupational health activities, and, to a trade union, the very existence of an EAP might represent an unacceptably high level of stress in an organization. Robertson (2006) quoted a manager for an advisory firm who supported this idea: “Companies don’t necessarily want to highlight the fact that [staff] can use an EAP because it brings the issue of stress to the fore” (p. 27).

Recommendations for Shifting to an Organizational Focus

Several authors have agreed that the emphasis on individual programs may actually weaken organizational and environmental change, shift responsibility to employees, and make people cope with stressors without addressing them. Like Shain (1996) and Murphy (1995), these authors responded by recommending changes in the EAP field. Dewe (1994) proposed a paradigm shift in EAP practice to a transactional approach focused on the organization-individual interface and including preventative and organizational change. Findings by Belicki and Woolcott (1996) "suggest that strategies aimed at modifying organizations, rather than just those directed towards individuals, should be considered when there is a desire to improve employee well being and efficacy" (pp. 44–45). Stennett-Brewer (1987) concluded "until the organizational dysfunction is addressed, there will be a continual and costly decline in morale, unit performance, and employee well-being" (p. 40).

Gathering and reporting data to the employer is a commonly identified role for EAPs, with an emphasis on protecting confidentiality. Nowack (2000) argued that EAPs need to feed information back to the organization to address work environment factors that cause stress. Donovan (2007) and Barrett (2005) proposed that data on or descriptions of EAP usage can help organizations identify and address "hot spots." Pitt-Catsouphes, Matz-Costa, and MacDonald (2007) presented EAPs as a way to provide data to identify places where people need family-friendly services such as flex time, time off to care for elders and adoptions, gradual return to work, and paid sick leave. Mayer (2001), Feltham (1997), Googins and Davidson (1993), and Megranahan (1990) argued that EAPs need to gather statistical information on workplace trends and stressors and feed it back to employers. In fact, Silcox (2005) described one company replacing an EAP that did not produce useful data with one that allowed identification of hot spots to target with job restructuring, workload reduction, and other interventions.

Ramanathan (1990, 1995) suggested that EAPs work to form social relationships among employees; advocate on behalf of groups of employees; consult with management and unions on quality of work life, workload, and work organization; and assist in the implementation of the Americans with Disabilities Act. Van Den Bergh (2000) argued that EAPs have the obligation to facilitate "family-friendly" services, build peer support, advocate for human HR policies to make employees feel less expendable, promote open communication and collaborative decision making, and support opportunities for employee education and development. Chima (2004) also proposed that occupational social workers address physical hazards, provide flexible scheduling, and promote other organizational changes to prevent stress leading to depression. Megranahan (1990) primarily emphasized individual counseling for individual change but added "There are likely to be occasions when the problem facing the individual should not be addressed in isolation from their work environment" (p. 8), with methods including "recommendations to the organization that it examines its approach to particular aspects of employee relations."

DISCUSSION

We are occupational health researchers exploring possibilities for integrating occupational health with workplace health promotion. This literature review was one component of our efforts to understand the EAP profession’s approach to job stress, its causes, consequences, and prevention. The results summarized in Sections 1 and 1.a. show that job stress is a major focus of concern for EAPs, and that the association between job stress and cardiovascular disease is well recognized.

Although several of the articles reviewed described stress as stemming from personal characteristics, the results summarized in Sections 3.a. and 3.b. describe organizational and environmental roots of stress consistent with the understanding prevalent in the occupational health field. Examples include high demand, low control, inflexible schedules, increased workload, and limited participation in decision making, role ambiguity, technological pressures, and job insecurity. Most of these articles also presented organizational-level interventions that can improve the work environment and reduce stress. However, they were split between those that argued that organization level interventions are not the role of EAPs, and those that argued that EAPs should intervene at the level of the organization.

Several articles described an historical trajectory toward a greater focus on addressing organizational roots of stress, starting in the late 1970s and continuing through the end of our literature review in 2008. This review, however, found no obvious temporal trend from, for example, a focus only on individual-level approaches in the 1980s to a focus on organizational approaches in more recent years. Rather, similar themes were found repeated throughout the time frame under review. Likewise, no particular type of approach or perspective seemed to be associated with the country of the first author or with authors listed as social workers versus psychologists, in ways that were apparent to the authors.

Several obstacles to an organizational focus were described. One, the contracting of external, rather than internal EAPs, seems especially common: Estimates from 1995 suggested that over one third of private nonagricultural work sites in the United States with 50 or more employers offered EAPs, of which 84% were external, 16% internal, and 5% both (Steele, 1998).

How visible is the organizational approach to stress in the literature for and about EAPs? We found, on average, about one article per year promoting organizational-level roots of job stress and=or interventions. As of November 16, 2009, the Google Scholar search engine shows that just six scholarly publications have cited Shain’s key 1996 article on the need for a shift to organizational approaches, and that three of these articles have the same first author.

Perhaps most tellingly, a 2009 article on "The Changing Nature and Future of EAPs" (Sharar, 2009) does not explicitly address job stress. This article, presenting "perspectives from four ‘thought leaders’" in one of the main journals for EAPs, argues that EAPs need to emphasize health and wellness, but also that their field is experiencing a "drift away from the actual workplace."

Several of the strongest criticisms of current practices are not EAPs (e.g., Murphy, 1995) or are engaged primarily in research and education (Berridge, 1999; Fitzgerald et al., 1989; Shain, 1996; Trubshaw & Dollard, 2001) and may not understand daily practical constraints faced by the profession. With the exception of describing worksites where EAPs feed back data to the organization, we were unable to identify accounts of organizational interventions led by EAPs. However, we recognize that most work by practitioners in the field is unlikely to be documented in journal articles.

Therefore a key question suggested by this review is whether organizational interventions have in fact become part of EAP practice, at least in some settings, or whether they are limited to recommendations. Addressing this question will require many more conversations with professionals in the field. Our research center began this inquiry, the results of which are outlined in the accompanying article (Nobrega, 2010).

By definition, the authors of this article are not EAPs and have approached this review from a starting point of nearly complete ignorance of the EA field. We are unfamiliar with the literature, history, and background of this field’s issues beyond those which emerged in the articles that matched our search criteria. Rather than presenting an in-depth analysis of the pertinent themes, we are summarizing the findings of outsiders who performed a defined exercise to start to form an acquaintance with a new potential ally. We hope that this is the beginning of a discussion in which EA professionals can start to explain to us what we missed.

The structure and organization of the workplace affect people’s health directly and also affect people’s behaviors and lifestyles in ways that in turn affect their health (Punnett, Cherniack, Henning, Morse, & Faghri, 2009). Many of these health effects and behaviors are traditional priority areas for EAPs. Occupational health practitioners are coming to understand the importance of collaborating with other professions to address the exposures and outcomes of common interest (Davis & Souza, 2009). This review has demonstrated that EAPs are not only acutely aware of job stress as one of their main concerns, but that certain leaders in the EA profession already possess extensive knowledge about work stress and organizational-level prevention. This means that, rather than working to introduce alien concepts into a different profession, occupational health practitioners may do best by seeking partnerships with these leaders and supporting the dissemination of their ideas within their own field. We are especially interested in learning from practitioners who have attempted, successfully or unsuccessfully, to put these ideas into practice and to develop their experiences into practical educational modules for others. We further pursue these themes in the accompanying description of in-depth interviews with practicing EAPs.