Occup. Med. Vol. 50, No. 5, pp. 315-319, 2000
Copyright © 2000 Lippincott Williams & Wilkins for SOM
Printed in Great Britain. All rights reserved
0962-7480/00
IN-DEPTH REVIEW
Interventions: what works., what
doesn't?
S. Reynolds
School of Health Policy and Practice, University of East Anglia, Norwich, UK
Key words: Counselling; mental health; occupational stress; organizational interventions; stress management training; well-being.
Occup. Med. Vol. 50, 315-319, 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)1603 593637; fax: +44 (0)1603 593604; e-mail: 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
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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.
316
Occup. Med. Vol. 50, 2000
COUNSELLING AND PSYCHOTHERAPY
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
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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 al9 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. Reynolds10 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 psy-
chotherapy, cognitive therapy and psychodynamic therapy, with depressed white collar and managerial
employees. Firth and Hardy14 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.
S. Reynolds: Interventions: what works, what doesn't?
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, Karasek1 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.
Warr23 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. Briner24
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 redesign4'25),
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 Reynolds26 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.
Reynolds10 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.
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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 Sorenson22
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.
317
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)
Experimental design
Minimal improvement
Not generally assessed
Psychotherapy for mental
health problems
Experimental design
Substantial improvement,
sustained at follow-up
Not generally assessed but some
evidence of improved work
perceptions
Stress management training
Experimental design
Modest improvement, short-term
No evidence
Organizational interventions
Quasi-experimental design
Small or no improvements
Small or no improvements
CONCLUSION
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.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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