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Occup. Mod. Vol. 47, No. 3, pp 133-141, 1997Copyright 1997 Rapid Science Pubfishers for SOMPrinted in Great Britain. Afl rights reserved0962-7480/97

Occupational stressmanagement programmes:a practical overview ofpublished effect studiesH. van der Hek and H . N. PlompVrije Universiteit, Social Medicine, van de Boechorststraat 7,1081 BT Amsterdam, The NetherlandsThere are many occupational stress management programmes available Which aredesigned to prevent and cure the negative aspects of job-stress. The focus of theprogrammes can be directed towards the individual worker, the working group, theorganization of the work or the organization as a whole. Moreover, programmesshow a considerable variation with respect to the type of interventions they promoteand their underlying assumptions, as well as their duration and costs. In this paper,effect studies of occupational stress programmes published between 1987 and 1994are reviewed. The aim is to give a practical overview of the variety in occupationalstress programmes, their scope, applicability and the evidence of their effectiveness.The paper updates the review by DeFrank and Cooper published in 1989.Key words. Effectiveness; evaluation, occupational stress, stress management programmes.Occup. Med. Vol. 47, 133-141, 1997Reanxd 26 February 1996;accepud in revised form 16 Daxmber 1996.

INTRODUCTIONOccupational stress is a major problem in westernsocieties. Its relationship with various diseases isbecoming increasingly obvious,1"3 but probably moreapparent are the vast socio-economic consequencesmanifested in absenteeism, labour turnover, loss ofproductivity and disability pension costs.4"6 In the UKthe Health and Safety Executive 7 has estimated thathalf of the absenteeism which occurs is due to work-stress; in the Netherlands the percentage of workerswho received a disability pension because of stress-related disorders (ICD-9, 309, adjustment disorder)increased between 1981-94 from 2 1% to 30% and thenum ber who to returned to work in the diagnosis groupis lower than in any other group.4

The first extensive review of the literature onoccupational stress management prog ramm es was con-ducted by Newman and Beehr,8 and published in 1979.Although personal and organizational strategies havebeen incorporated, they conclude that most of thestrategies reviewed were based on professionalopinions, and that very few strategies have been evalu-Correspondence and reprint requests to: H. van der Hek, Institute forHuman Research Management, Jan van Nassaustraat 16, 2596 BP's-Gravenhage, The Netherlands

ated directly with any scientific rigour. This impliesthat 'practitioners have little more than their commonsense and visceral instincts to rely on when they attemptto develop badly needed preventive and curative stressmanagement interventions' . DeFrank and Cooper9launched a review on the same subject in 1989,covering the literature up to 1987. Th ey conclude thatin comparison with the findings of Newman and Beehr,8substantial progress has been m ade. Stress man agementprogramme evaluation has become more systematicand rigorous. The present review is an update of thereview of DeFrank and Cooper;9 effect studies ofoccupational stress management programmes publishedfrom 1987-94 are identified, summarized and evalu-ated with respect to their effectiveness and application.The paper intends to offer a practical overview of theevaluated progr amm es and to assess the state of affairswith respect to evaluation research in the field ofoccupational stress management programmes.

MATERIALS AND METHODS

Inclusion of studiesComputer-based searches were consecutively conductedin three CD -RO M data-bases that include the relevant

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s c i e n t i fi c r e s e a r c h : P s y c L I T ( p s y c h o l o g i c a l ) ,SOPADO (sociological) and Medline (medical). Toidentify those studies published between 1987 and1994 which evaluate the effectiveness of occupationalst ress management programmes, the following keywords w ere used: occup ational (or job- or work-) stressi n com bi na t i on w i t h i n t e r ven t i on ( p r og r am m e,program, therapy or management) . A considerableover l ap be tween the t h ree CD-ROM data-basesappears; after the searches in PsycLIT andSOPADO,the Medline search did not produce any additionalstudies. In the first run, 342 abstracts were identifiedand screened. When it became obvious from theabstract that the effectiveness of a stress managementprogramme was evaluated, attempts were made toobtain th e original article. Only 37 of the 342 abstractsrefer to some kind of evaluation research, which indi-cates the relative scarcity of evaluation studies on thissubject, compared with purely descriptive or theoreti-cal studies. Eventually, only two articles 10 '11 could notbe obtained through the library services. After screen-in g the articles collected, only 24 studies wereultimately included in the review. Seven studies12 "18were left out of the review because the evaluation waspurely anecdotal , i.e., the training was only rated aseffective on the basis of comments from the partici-pants . Two s tudies were excluded because they focusedon specific sources of stress (merger or acquisition19"20),and two other studies2 1 '2 2 were excluded because theintervention was directed towards workers who hadbeen given a psych iatric diagnosis of 'major depression'.

Classification of occupational stressmanagement programmesStress management programmes vary widely with

respect to objectives, type of intervention, structureand target group. In occupational stress managementprogramme s this variation is even greater because notonly employees, as individual or as a group, but alsothe organization itself could be subjected to interven-tion programmes. In the literature, several categoriesare applied to classify occupational stress managementprogrammes. Matteson2 3 draws a distinction betweenpreventive and curative strategies. Murphy 2 4 empha-sizes three levels of intervention: primary (stressorreduction), secondary (stress management) and terti-ary (Employee Assistance Programs). Newman andBeehr8 use a classification of 12 categories based onthe different types of adaptive responses or partici-pants (person, organization, outsider), the primarytarget (person, organizat ion) and the nature ofresponse (preventive, curative). A more simple classi-fication is given by D eFr ank and Cooper9 whodistinguish interventions as well as outcomes (targets)of stress management programmes on three levels:individual , individual-organizat ion inter face, andorganization. The DeFrank andCooper9 classificationis used in this paper to subsume the reviewed studiesas represented in Scheme I.Review: process and p r e s e n t a t i o nThe studies included in the review are summarizedby the authors of this pape r independently on differentaspects. The summaries are included in Scheme II inthree columns. In the first column the programmes arecharacterized according to the aspects: type of pro-gramme, size of the target group, duration and numberof the sessions andqualification of the trainer(s). Theimportance of an experienced trainer is illustrated bythe findings of Butcher,2 3 who evaluates two training

Scheme 1. Reviewed effect studies classified by level of intervention(s) and level of outcome measures (studies with more thanone outcome level are printed in italic; studies with more than one intervention-level are printed bold)Level of interventions Level of outcome measures

A. Individualmood states [e.g., depression);psycho-somatic complaints;subjective experienced stress;physiological parameters;sleep disturbances;life-satisfaction

B. Individual-organizationInterfacejob-stress-satisfaction;burn-out;performance;health-care utilization

C. Organizationproductivity;turn-over;absenteeism;health-insurance claim;recruitment

A. Individual(relaxation/meditation/bio-feedback; cognitive copingstrategies; Employee Assis-tance Programmes)B. Individual-organizationalInterface(relationships at work; person-environment fit; role issues;workers participation andautonomy)C. Organization(organizational structure;selection and placement;training; physical and environ-mental; job (restruc turing;health concerns and resources)

25 , 26, 27, 2 8, 29 , 30 , 31 , 32,33 , 34 , 35 , 36, 37 , 38, 39, 40,41, 42, 44, 45

45 , 46

47 , 48

25, 27, 29, 31, 33, 34, 37 , 4041, 43 , 45

45

48

33 , 36 , 43

47 , 48

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H. van der Hek and H. N Plomp: Occupational stress managem ent programmes 135

groups and found better results when the trainer hadmore experience. Outcome measures which indicatethe scope of the studies are included in the secondc o lum n, measurement characteristics. Although this paperdoes not go deeply into matters of methodology, somecrucial issues regarding the research design (controlgroup, follow-up period, if any) are added in diiscolumn to indicate the persuasiveness of the study.Outcomes are summarized in the last column of schemen.In the results paragrap h occupational stress m anage-ment programmes are summarized per category ofprogrammes more extensively. The evidence of theeffectiveness of all reviewed studies is assessed on thebasis of the quality of design and the limited scopeindicated by the specific character of the target groupsand the outcome parameters applied.

RESULTSThe reviewed studies are classified in Scheme Iaccording to the DeFrank and Cooper9 classificationof occupational stress management programmes. Inthe great majority of reported studies, interventionsfocus on the individual level. Interventions on this levelvary considerably: from relaxation, meditation tech-niques, bio-feedback, cognitive coping strategies toindividual counselling. Outcome measures on theindividual level also show great variation well: physio-logical parameters (e.g., blood pressure, muscle tension),psych om etric scales of mood states, self-reported stresssymptoms and satisfaction with life. On the individual-organizational interface level, interventions are directedtowards a bet ter person-environment-f i t throughstrengthening social support or job-enrichment; out-come measures range from self-reported experiences(e.g., job-stress, burnout) to health behaviour. Inter-vention on the organizational level are organizationaldevelopment schemes and restructuring of jobs, whilethe outcome measures are productivity, absenteeismrates and health insurance claims. Scheme I shows thatmost studies with interventions on the individual levelalso have outcome measures_on the individual-organ-izational interface level. Only two of the 24 studiesreviewed evaluate an intervention on the individual-organizational interface level and two studies alsoconcern interventions on the organizational level.However, compared with the 1987 review of DeFrankand Cooper,9 this is a better score, because they didnot trace any effect studies with interventions on theselevels. Although there is general recognition that workand organizational problems are the major causes ofoccupational work-stress,49 there is still a lack ofresearch into interventions on this level. The lowproportion of studies including interventions directedtowards the se causes does not necessarily give a correctrepresentation of their actual occurrence; a metho-dologically sound evaluation on organizational level isusually much more difficult to implement.

O c c u p a t io n a l s t re s s m a n a g e m e n t p r o g r a m m e sIndividual level. Although programmes apply differ-ent interventions, and many include more than oneintervention (so called multi-model programmes2 5"31 ),their structures are comparable. Programmes usuallycommence with an educational phase, in whichparticipants learn about the causes and consequencesof occupational stress. Subsequendy, a cognitive skillcomponent is included, such as cognitive coping skillsor time-management, which is intended to change theway in which people structure and organize their work-ing situation. Finally, relaxation and/or meditationtechniques are included, which target the physicalconcomitants of stress, such as muscle tension or bloodpressure. Despite the similarity in structure, immensedifferences appear with respect to group size (6-27per grou p; average of 12), duration of the programm e(4-24 hours) and the period of implementation (fromhalf a day to 12 weeks). No reason s are given for thesevast differences, but the information is relevant whenconsidering the costs and time impact of the pr o-grammes on the regular work-flow.Relaxation/meditation. Relaxation methods can bedistinguished in two categories: those ones that arephysiologically oriented, aiming at the achievement ofdeep muscle relaxation through contracting and relax-ing major muscle groups and, on the other hand, thecognit ive-oriented methods achieving relaxat ionthrough imagery and meditation. Relaxation tech-niques are often used as a complementary techniquein multimodel programmes. Three of the studiesincluded in the review evaluate this technique as asingle intervention, and are good examples of alterna-tive methods. Murphy 43 uses a muscle relaxationtechnique which is taught to the participants by meansof cassette tapes which describe muscle tension andrelaxation exercises. Toivanen36 describes an easyrelaxation exercise, which needs only to be practisedfor 15 minutes a day. The participants are taught: (1)deep diaphragm breathing with the full vital capacityto possibly also improve the normal breathing and torelax the muscle structure s involved; (2) forced tensionand relaxation of the abdominal muscles to relax themand to 'massage' the abdomen; (3) deep relaxationalong with simple suggestions for relaxing, to achieverelaxation, also focusing the m ind on gradually calmingthe breathing. Tsai37 applies the cognitive methodwhich includes three cognitive processes: focusing,passivity and receptivity. Focusing is the ability toidentify, differentiate, maintain attention on and returnattention to simple stimuli for an extended period oftime. Passivity is the ability to stop unnecessary goal-directed and analytic activity. Receptivity is the abilityto tolerate and accept experiences that may beuncertain, unfamiliar or paradoxical. In the progressof relaxation, focusing, passivity, and receptivity isincorporated into the cognitive process, and the out-come of such relaxation is a calm mind and a relaxed



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136 Occu p. Mod Vol 47, 1997

Scheme II. Summaries of reviewed effect studies on occupational stress management programmesStudyFirst author. target group. intervention level

ProgrammesType of programme/group-size/duration and time-frame/qualification of trainerMeasurementoutcome measures/controlgroup/follow-up period

Outcomes

Butcher : 1988^. Community healthworkers. Indiv idualNorvel l : 1987 28. Respiratory therapists. Indiv idualBertoch: 1989 27. Teachers. Indiv idualJohansson: 1 99 1 28. Nurses. Indiv idualMcCue: 1 9 9 1 29. Medical Residents. Indiv idualReynolds : 1993 30. Health serviceworkers. IndividualSchaufel i : 1994 31. Community nurses. Indiv idual

Mult imodel t raining/First t raininggroup of 27, second training groupof 13 persons/3 hour sessions perweek for 3 weeks/No trainerquali f icat ion ment ionedMult imodel t raining/Group size s ixpersons/1 hour session per weekfor 8 weeks/Master's levelpsychologistsMult imodel t raining/Group size 15persons/2 hour sessions per weekfor 12 weeks/Clinical psychologistMult imodel t raining/Group size max.nine persons/2 x 50 minutes perweek for 3 weeks/No trainerquali f icat ion ment ionedMult imodel t raining/Group size13-16 persons/4 hours on one day/No trainer qual i f icat ion ment ionedMult imodel t raining/Group size ninepersons/2 hour sessions per weekfor 6 weeks/Clinical psychologistMult imodel t raining/Group size notment ionecl/3 day workshopNo trainer qual i f icat ion ment ioned

Barkham: 1990 32. White col lar workers. Indiv idualCooper : 1990 33. Post-of f ice employees. Indiv idual

Psychotherapy/ lndiv idual/2 sessions+ 1 af ter 3 months/ Cl inicalpsychologistsPsychotherapy/Indiv idual/Average ofthree sessions/Clinical psychologists

Keyes : 1988 34. Staf f working withmental ly retarded. Indiv idualLong: 198835. Teachers. Indiv idual

Toivanen: 1993 3*. Hospital c leaners. Individual

Tsai: 1993 37. Nurses. Indiv idual

Woods : 1987 38. White-col lar workers. Indiv idualKushnir: 1993 39. Senior safety officers. Indiv idual

Stress Inoculat ion Training (SIT)/Group s ize 12-16 persons /One dayworkshop/No trainer qual i f icat ionment ionedStress Inoculat ion Training (SIT)/Group size 7-12 persons/1.5 hourper week for 8 weeks/Experiencedgroup leaders

Relaxat ion t raining/Group size notment loned/3 x 15 minutes per weekfor 3 weeks/No trainer qual i f icat ionment ioned

Relaxat ion t raining/Group size 23persons/2 x 90 minutes per weekand fol low-up session af ter 5weeks/No trainer qual i f icat ionment ionedRat ional Emot ive Training (RET)/Group size 8-14 persons/1.5 hourper week for 4 weeks/ExperiencedRET trainerRat ional Emot ive Training (RET)/Group size 22 persons/4 hoursessions per week for 5 weeks/Expenenced RET t ra iner

Perceived knowledge andabil i t ies; Actual knowledge/Nocontrol group/Fol low-up 4 months

Burnout; Physical symptoms;Hassels and Upli f ts Scale/Waiting list control group/Nofol low-up periodStress levels; Clinical ratingscale/ Waiting list controlgroup/No follow-upAnxiety; Depression/Minimaltreatment control group/No fol low-upBurnout; Stress levels; Lifeexpectancy survey/Controlgroup/Fol low-up 6 weeksEvaluat ion; Session impactrat ing/No control group)No fol low-upSomatic complaints;Psychological strain; Burnout;Job performance; React iv i ty/No control group/Fol low-up 1 monthDepression; Symptomcheckl ist /Normat ive control data/Fol low-up 6 months 'Anxiety; Depression; Somaticanxiety; Self -esteem; Jobsat isfact ion; Organizat ionalcommitment, Sickness absencedays/Normat ive control data/Fol low-up 6 monthsAnger Inventory; Emergencyretains rating/Attention controlgroup/Fol low-up 5 months

Anxiety; Teachers ' stress;Coping; VO2 max-cardiovascularf i tness/Delayed treatment controlgroup/Fol low-up 8 weeks

EMG levels; Diary; Absenteeismrat ings; Depression/ Controlgroup/Fol low-up 6 months

Work stress; General HealthQuest ionnaire/Placebo controlgroup/No fol low-up

Physical symptoms; Anxiety;Depression; I rrat ional bel iefs/No control group/Fol low-up 3-4monthsCognit ive weariness; Somaticcomplaints; Assert iveness;Irrat ional Bel iefs/Controlgroup/Fol low-up 18 months

Post-test scores significant changes onmeasurements, only for second training groupchanges maintained at fol low-up. This is explainedby the experience from the therapist with the firstt raining group.Support that a vanety of stress managementtechniques can be ef fect ive in enhancing emot ionalfunctioning. However, only two out of 11 scales aresignif icantSubstantial decrease in stress levels after thetreatment compared to control group. Morefocused treatment on individual needs Isrecommended.Significant lower anxiety and depression scores forthe t reatment group compared to control group.

Training was received positively and can lead tosignificant short-term improvement in stress andburnout test scores.Time management and introductory sessions hadfew impacts on participants. Relaxation, relationships,cognit ive strategies and dealing with emot ions hada distinctive and predicted positive impact.Treatment is effective in decreasing mental andphysical symptoms, but not job performance.Moderating role of reactivity. Low reactive nurses,who are already rather resistant to stress benefitmost f rom the workshop.At fol low-up 53-75%, depending on the scale thatis used, of the clients have Improved to normalfunct ioning.Significant decline in sickness absence, anxietylevels, somatic anxiety, depression and increase inself -esteem. No changes in job sat isfact ion ororganizat ional commitment.

Decrease In scores on anger inventory, frequencyof emergency restraints significantly reducedcompared to the period prior to the training. Formales a larger reduction in anger scores reportedcompared to females fol lowing the training.SIT with exercise more effective in reducinganxiety and stress compared to minimal t reatment,although both groups significantly decreaseemotion focused and increase of prevent ivecoping. SIT without exercise component had nosignificant effect on anxiety, stress or copingstrategies. This is probably due to the time-frameand design of the experiment. Subgroup ofhigh-anxious/low fitness benefit most.Relaxation training effective in reducingneck-shoulder tension, but the decrease Inabsenteeism rates can not be attributed to therelaxat ion t raining because control group shows acomparable decrease, which is explained by thesocial support from the researcher.Signif icant dif ference between experimental andcontrol group after 5 weeks. Duration of practicesignificant factor on self reported work-stresslevels. Control group also snows decrease inreported levels, which is explained as reactivityand contaminat ion ef fects.Three to four months after the training majorchanges on al l outcome measures and thesechanges are related to changes in irrational beliefs.After 18 months the improvements on themeasurements still evident, but not In the sameextent as snort term effects. Booster session isadvised. No fol low-up data is avai lable for controlgroup.

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Scheme II. Continued.H. van der Hek and H. N. Ptomp: Occupational stress management programmes 137

StudyFirst author. target group. intervention levelProgrammesType of programme/group-size/duration and time-frame/qualification of trainer

Measurementoutcome measures/controlgroup/follow-up periodOutcomes

Hyma n : 199340. Staff in long-termcare facility. IndividualSall is: 198741. Hi- tech personnel. Individual

Brunlng: 198742. Hospital equipmentpersonnel. Individual

Murphy: 1988 43. Highwaymaintenanceworkers. IndividualJenkins: 199044. Teachers. Individual

Cec i l : 199045. Teachers. Individual-organizational

Grossman: 1993 48. Hospital staff. Indvtdual-organizationalJones: 198847. Hospital staff. Organizat ional

Go lembiewski : 198748. Management team. Organizat ional

Experient ia l group training/Groupsize not mentioned/3 hour sessionsfor 3 weeks/No trainer qualificationmentionedThree dif ferent training programmes:relaxation training group, muftimodeltraining, education-support group;Group size 11-16 persons/1 hourper week for 8 weeks/No trainerqualification mentionedThree dif ferent training programmes:management skil ls, meditat ion,exercise; after 13 weeks groupsreceive a combination of theprogrammes/8-10 hour training infirst week, which Is repeated after13 weeks / Group size 15-16persons/One of the researchersTwo dif ferent training programmes:blofeedback, muscle relaxation;group size 2-4 persons/ 1 hourdaily for two weeks/ Cassette tapesTwo dif ferent training programmes:individualized training method step by step development of anindividualized plan and a globaltraining approach focus ongeneral knowledge; group size notmentioned/3 hour sessions for 2weeks/No trainer qualif icat ionmentionedTwo dif ferent training programmes:stress Inoculation training (SIT) andco-workers support group; groupsize not mentioned/1.5 hour perweek for 6 weeks/No trainerqualification mentionedSupport groups/Group size 8-15persons/1.5 hour per week for10-15 weeks/Socia l workers,psychiatric nurses or psychologistsOrganizat ion-wide stressmanagement program/All membersof the organization/Total durationone year/No trainer qualificationmentionedOrganizat ional Development/Allmembers of the organization/ Totaldurat ion 13 months/No trainerqualif icat ion mentioned

Burnout; Work atmosphererat ing; Benefit workshoprating/No control group/Nofollow-upBlood pressure; Anxiety;Depression; Hosti l i ty; Jobsatisfact ion/Education-supportgroup is minimal treatmentcontrol group/Follow-up 3 monthsPulse rates; Blood pressure;Galvanic skin response/Controlgroup only during first trainingweek/No follow-up period

Absenteeism; Performancerat ings; Equipment acc idents;Work injuries/Control group/Follow-up 1.5 yearSurvey about the workshop/No control group/Follow-up 3 weeks

Personal and organizationalstress levels; Coping skills;Teacher anxiety observations/No control group/Follow-up 1 monthEvaluation report/No controlgroup/No follow-up period

Medical malpract ice claims/Matched control group/Follow-up 1 year

Burnout; Job Involvement; Workenvironment; Turnover rates/No control group/No follow-up

Statistical improvement for the scales personalaccomplishment and emotional exhaustion. Alsorat ing work atmosphere improved. Retrospectivepretest design is used.Significant reduction In anxiety, depression andhostility, maintained at follow-up measurement. Noimprovement on job sat isfact ion, work stress andblood pressure. No evidence that one group wasmore effective than the other, even education-support group shows comparable changes.All three training programs resulted in significantreductions in pulse rate and systolic bloodpressure compared to control group, none of theprograms was more effect ive.

There is limited support found for relaxationtraining on absenteeism one year after thetreatment, not on the other measures. Sixmonths later this effect also diminished.Teachers who received the individual training didsignificantly increase the time they spend onmanaging stress, and used a greater diversity ofmethods to handle stress compared to the globaltraining approach. Both training methods had thesame conten t

SIT was effective in reducing self reported stress,while the co-worker support group was not.Neither treatment successful in changing motoncmanifestations of anxiety in the classroom.

Appear to be effective in alleviating stress. Aproblem is the high drop-out rates (people whoneed it most).Hospitals that implemented an organization-widestress management program had significantlyfewer claims compared with a matched sample ofhospitalsLevel of burnout diminished and remainedreduced for at least four months, decreasedsomewha t in the fol lowing nine m ore m onths.Improvement in group properties and turnoverrates persisted.

body functioning. The relaxation technique includedbreathing exercise, imagery and meditation, withspecial emphasis on the underlying cognitive processof meditation proposed by Smith.50 Another medita-tion-relaxation techniq ue applied in a study 42 wasdeveloped by Carrington.51 In this method the partici-pants are instructed to sit quietly and meditate for 15to 20 min once or twice a day. The participants begineach meditation session by calming and relaxing thebody. Then they spend the remaining time workingwith a mantra (meditation sound), which has beenchosen by the participant from a number of suchsounds selected by Carrington.51

Biofeedback. Biofeedback was evaluated by Murphy 43as a separate intervention technique, but is usuallyemployed in combination with relaxation. When therelaxation exercises are practised, the participantsreceive immediate response (feedback) measurementsfrom an electromyogram (EMG). Biofeedback isprovided by a finger thermometer and a galvanic skin-resistance monitor, which the participants use to findout if they are successful in dilating peripheral bloodvessels and decreasing sweat-gland activity. Anotherway of giving biofeedback is men tioned by Johansson 2 8who, in connection with autogenic training uses selectphrases (e.g., 'the feeling of heaviness is growing across


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my shoulders and arms; I am relaxing deeper anddeeper ' ) which should be repeated wi th intenseconcentrat ion.Methods which provide the participant of a stressmanagement programme with an immediate responseon the effect of the exercises are especially helpful inteaching them the most effective way of to achieverelaxation.Cognitive coping strategies. Cognitive co ping strategiesare derived from psychotherapy, and are based on theconcept that human behaviour and emotions can beinfluenced by a change in cognition. Two categoriesof cognitive coping strategies can be distinguished: thecognitive restructuring strategies, aiming at die reduc-tion of stress, and the coping skill strategies directedtowards the development of personal strategies aimedat improving skil ls and competencies to meet thedemands of the job. The rational emotive therapy ofEllis31 '38 '39 is an example of the cognitive restructuringstrategy. The appraisal and reappraisal model of Beck 33and the self-instruction therapy of Meichenbaum 2 8 areexamples of the coping skill strategy.

Cognitive restructuring involves training in positivecoping self-statements {e.g., 'One step at a t ime'; ' Ican handle the situation') that encourage realist icassessment of situations, control over self-defeatingthoughts, preparation to confront potential stressors,coping with fear and reinforcement of successfulcoping behaviour.The s t r ess inocula t ion t r a in ing developed byMeichenbaum5 2 is one of the most famous cognitivecoping skill strategies. The programme focuses on suchactivit ies as goal-sett ing, t ime-management, commu-nica t ion sk i l ls , conf l ic t r eso lu t ion and problemarticulation skills. For example, in Bruning's 42 studyparticipants were instructed to explore both work andpersonal values and then to set themselves both stra-tegic and tactical goals. They were taught to pinpointgoals, to seek the collaboration of fellow workersregarding these objectives and to identify road-blocks.Most of the studies use a method of education anddiscussion. In Bertoch's 2 7 study the participants dis-cuss customary ways of coping with disappointmentand explore less stressful alternatives. Another formof this method is used by Butcher, 2 5 who provides theparticipants of his study with 'stress scripts' in whichcognitive, emotional and behavioural directions forconstructive reactions to stress situations are explained.An example of how problem articulation skills canbe taught is given by Hyman 40 in an exercise in whicheach participant had to communicate the correct orderof a series of items to a partner, while sitting back-to-back. In another exercise, an 'accident report ' wasread aloud and then transmitted verbally to a seriesof volunteers who had not heard or seen the writtenrepor t .Employee Assistance Programmes (EAP). The EmployeeAssistance Programmes (EAP) were applied in the

studies of both Cooper and Barkham.32 '33 Both studiesinvolve different forms of psychotherapy given to highlystressed individuals. The intervention is, in con trast tothe other studies, curative in na ture. Barkham's32 studycan be considered an EAP which takes place outsidethe organization. All the participants of the study werereferred to his psychological clinic because of work-related problems. He describes a brief therapeuticmodel comprising two weekly sessions of therapy,followed by a third session three months later. Twomodes of therapy are presented within this model: abrief cognitivebehavioural package, called 'prescrip-tive therapy', and a brief relationship-oriented packag e,called 'exploratory therapy'. Cooper's study 33 is anexample of an in-house EAP offered by the Occupa-tional Health Services of British Mail. It was assumedthat an in-house counselling service would have thebenefit of a broad knowledge of the business andworking methods, and would be more able to under-stand and help the employees. Anotiier importantaspect in the choice of an in-house service was thefunction of signalling to the management, whenproblems seemed to be organizational rather thanindividual. The counselling was based on Rogerianpsychotherapy , and an average of diree sessions p rovedto be enough to help the people who made use of theservice because of work-related problems.Individualorganizational interface level. On the indi-vidual/organizational level two studies45'4* were iden tifiedwhich were directed towards strengthening socialsupport. Bom studies describe co-worker support groupswhich primarily aim to improve the individual-organi-zation relationship (instead of changing individualcharacteristics). The groups are networks of peoplewho occupy similar positions in an organization andconsider themselves to have common needs and goals.These people meet to solve common problems,support each other and improve their skills. Despitethe lack of evaluation data concerning this interven tion,co-worker support groups have been described innumerous professional publications as an importantentity in the prevention of occupational stress inemployment settings.45 The primary emphasis of thegroup meetings was to share problems, give reassur-ance and support, share successful coping strategiesand to listen emphatically.

In both studies there seemed to be one majorproblem: embedding in the organization. Groups ofvolunteers from various schools were evaluated, whichmade external interaction difficult.Organizational level. Two studies were identified inwhich the stress prevention programme focused onthe ent i r e organiza t ion . The organiza t ion-wideprogram me descr ibed by Jones47 star ted wi th anassessment of stress levels, and subsequend y a five-stepintervention was implemented. In the first step, theresults from the survey were reported to senior man-agement and suggestions were made for amending

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organizational factors that may cause employee stress.Secondly, the managers of the departments in whichthe highest stress levels occurred, worked out a seriesof policy and procedural changes to reduce stress, withwhich they were able to obtain support from externalconsultants. These changes concerned inter-depart-mental communication, organization and personnelpolicies. Du ring the third step, the senior m anagementdiscussed the survey resu lts with all employees in smallconference sessions. In the fourth step all employeeswere shown a series of video-cassette training modules.They were designed to increase recognition andunderstanding of stress and to teach them how toimprove their coping skills in dealing with both work-place and personal stress. Finally, a comprehensiveemployee assistance programme was set up to provideemployees with help and counselling for work-relatedand personal problems.

The second study of Golembiewski48 describes ah igh-s t imulus o rgan iza t iona l deve lopment (OD)programme aiming at the development of a socio-emo-tional infrastructure to generate and support changesin policies, procedu res and structures. The programm eaims to create an organizational culture and provisionsto meet individual needs and eliminate the causes ofstress. This approach involves the participation of allmembers of an organization in the diagnosis andsolution of prob lem s. To sta rt w ith, all employees wereasked to list the three things they considered best intheir department and the three things they consideredworst and urgently in need of change. The outcomeswere discussed in a general meeting and reported tothe Vice-President. S ubsequendy, g roups of volunteerswere formed to gather additional information and makerecommen dations for improvem ent. Th e objective wasto formulate values and to create appropriate provi-sions and relationships for support in work and tasks.An example of a concrete outcome is the developmentof a career policy.

E V I D E N C E O F E F F E C T I V E N E S SMost of the studies summarized in Scheme II showsome kind of effect, but no consistent overall pictureemerges. Although all interventions are intended toprevent and combat stress, they produce differentialeffects. Some studies reported effects over one yearand longer,39 '43 but most did not measure such long-term effects and in nine studies no follow-up periodat all was included, which in itself is a serious metho-dological shortcoming.

Sometimes an intervention (co-worker support group)which brings about the intended effect in one group, 46does not do so in another, 45 which indicates theimportant influence of confounding or modifying factors.The qualification of the trainer is mentioned as acrucial modifier in the study of Butcher,2 5 and genderin the study of Keyes.34 Control groups make control-ling for these effects possible, but in 10 out of the 24studies there are no control groups. Despite methodo-

logical shortcomings, the major problem in drawingconclusions about the most effective occupationalstress management programmes is the fact that thereviewed studies are difficult to compare, due to theirheterogeneity. They vary with respect to target groupand target, as indicated by the outcome parameters.Target groups. Th e method of recruitment determines,to a large extent, die type of workers who will partici-pate and also their expectations with regard to theprogramme. Most participants in stress managementprogrammes join on a voluntary basis, but in organi-zation-oriented programmes it is often more difficultto abstain from participation. At the same time theeffectiveness of an intervention can be dependent onthe type of workers who participate. This is demon-strated in the study of Long, 35 in which it appears thathigh anxiety scores at inclusion in the programmeresult in greater effectiveness in the outcome parame-ters. It has been found that programmes in whichparticipation is entirely voluntary, attract the so-called'worried well' people who recognize the stressors intheir work, but who are quite capable of coping withthem. Schaufeli,31 who conducted a workshop for com-munity nurses, found that the average level of burnoutwas significantly lower among workshop participantsthan am ong a comparable group of comm unity nurses.The researchers assumed a selection effect: the nurseswho felt least burnt out decided to participate in thewo rkshop , whereas for their colleagues, who were mo reburnt out, participation might have been too threat-ening. A final indication that voluntary participationdoes n ot attract the workers at risk comes from Sallis:41in his study the participants, employees of two 'high-tech' corporations, reported baseline values very similarto the means of the normative samples on all psycho-logical variables (anxiety, depression and hostility). Definition of the target gro up and the method ofrecruitment should be an important point of consid-eration. In research, the definition of the target groupis the basis for generalization of the results, and is themost practical point of departure when designing astress-management programme.

Targets and interventions. To assess the effectivenessof interventions directed towards stress prevention oralleviation, specification of the target is crucial. Therelationship between the intervention and the targetshould be entirely clear when the programme is initi-ated, and should be proved when the programme hasbeen implemented. Interventions on the individuallevel usually bring about the most convincing effecton the individual outcome param eters. Murph y's study,reporting a temporary effect of decreasing absenteeismamong highway maintenance w orkers, is an exception.However, at die end of the paper he concludes: 'as aprimary strategy to reduce employee stress at work,stress management has significant limitations, since noattempt is made to alter the sources of work-stress';in other words: another type of intervention would



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140 Occ up. Med. Vol. 47, 1997

have been more effective in achieving this target.Interventions tailored to the needs and demands ofindividual problems have a greater effect on stressoutcome measures than standard interventions.2 7 TheGolembiewski study, which focuses on the organiza-tional level but also applies methods on the individualand organization-individual interface level, showsconvincing effects on all three levels.Targets can be defined as the intended outcomes as,for instance, indicated in Scheme I; they can refer tospecific groups at risk because of their workload orage. Targets can also involve primary, secondary ortertiary prev ention, which is discussed in the Materialsand Methods section of this paper.

C O N C L U S I O N S

not reflected in the effect parameters. The mostexpensive interventions (expressed in time per p artici-pant) even produce the lowest effects.^Practitioners are still left with a considerable amountof uncertainty with respect to the choice of good stressmanagement programmes. Useful strategies for theimplementation of stress management programmeshave been published by Karasek 49 or Williams.53 It iscrucial to start by determining which workers are atrisk and what constitutes risky working conditions;screenings instruments can be used, a stress audit canbe organized, or absenteeism and turnover rates ana-lyzed. The next step is the choice and implementationof an intervention. Cost-effectiveness analyses areimportant to ensure management suppo rt , but partici-pation of the workers in the preparation phase isessential for the success of the programme.

In comparison with the review published in 1989 byDeFrank and Cooper ,9 the number of effect studieson occupational stress management programmes isincreasing and studies including interventions onorganizational level have also been identified. However,it is still impossible to determine which specific inter-ventions or techniques are most effective and shouldbe recommended. There is some evidence that organi-zat ion-wide approaches show the best resul ts onindividual, individual-organizational interface andorganizational parameters; these comprehensive pro-g r a m m es have a s t r ong i m pac t on t he en t i r eorganization, and require the full support of the man-agement. From a methodological perspective, however,it is not clear what exactly causes the effects: thecommitment and willingness of management to investin human resources, the quality of the single pro-gramme components, or simply the combination of allthese factors. Knowledge about the effectiveness ofsingle components of stress management programmesis imp orta nt, no t only for the accu mulation of scientificknowledge on stress prevention and treatment, but alsoto assist smaller organizations which are not in aposit ion to implement comprehensive programmes.The aim of future research should be to establishcredibility as to what stress management programmescan or can not accomplish, and under which circum-stances.

The lack of accumulation of empirical evidence onthe effectiveness of interventions directed towardsstress preventio n, is not primarily caused by a shortageof studies, but by the considerable heterogeneity ofstudies, which makes it difficult to compare variousempirical studies. There is an urgent need for betterconceptualization and theoretical reflection on stressmanagement programmes and the type of effects thatcould be expected under which conditions and forwhat length of time.A priority for future research should be determina-tion of the cost-effectiveness of interventions. Ourreview shows enormous differences in time duration(from 9 min pe r individual to 12 h) that are absolutely

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