'De-stressing the Workforce'
Occupational Health, 01 Jan 04

Employee assistance programmes and counselling are increasingly popular mental health interventions. But how do they actually work in practice? By Tim Cuthell

Employee assistance programmes (EAPs) have become increasingly familiar in the UK since they first evolved from the welfare counselling services of the 1970s. EAPs play a central role in stress management by offering a range of services to employees and, usually, their relatives.

Unlike their counterparts in the US, UK EAPs are almost entirely used on a self-referral basis, with the employee or their family member contacting the service directly for help.

This reactive use of counselling and advisory services is generally accepted as a positive intervention that will help users to understand their problems and formulate strategies and actions to resolve them. By doing so, the support provided by EAPs can help to reduce stress, whether it is in the workplace, at home, or in both.

However, self-referral often happens only once a problem has grown into a crisis, and relies on the individual recognising that they have a problem. This severely restricts the role that an EAP can play because many people who would benefit from help do not, or will not, recognise that they have a problem and are, therefore, unlikely to contact their EAP – in fact, only between 5 and 15 per cent of employees do so in the UK.

Modern OH services operate differently. The majority of referrals are initiated by management, and self-referrals, if available, play a lesser role. This means OH advisers are more active in the process of identifying symptoms and encouraging employees to seek help and treatment. But, even then, this only occurs once the OH adviser knows the employee.

As a result, many employees with a variety of problems, be they physical, emotional, behavioural or psychological, will not get help until their problem is ‘big enough to warrant help’. Even then, not all employees will accept or ask for help – after all, the fear of losing your job is one of the greatest concerns in modern life. It is no surprise then that people do not, as a rule, rush to tell their employer, or someone paid by their company, that they have a problem that could make them less efficient and effective at work.

So what is the answer? We need to go looking for these people and, once we find them, we need to be able to take some kind of ethical action to encourage them to get help.

Managing stress proactively

Stress is a symptom, not a diagnosis. The Health and Safety Executive (HSE) defines work-related stress as ‘the adverse reaction people have to excessive pressures or other types of demand placed on them’.

How do you identify stress? This is an important question for OH practitioners. The reality is that one is very unlikely to see stress other than in the most extreme cases, such as violent outburts – for example, road rage, nervous reactions (shaking, crying, sweating or running away), or symptoms of post-traumatic stress disorder (PTSD).

In most cases, the adverse reaction described by the HSE is a less noticeable, often secret, reaction to stress. The problem is usually related to a loss of feeling in control, and the consequent discomfort and anxiety will manifest itself in a variety of different behaviours.

What can you identify then? Performance at work is the most likely clue. These factors are easily identified once a stress problem has escalated to crisis point.

To recognise them sooner requires skill and experience, along with the ability to empathise and recognise tension, anxiety and the feelings of oneself and of others (this capability is also known as emotional intelligence).

Knowing how employees usually act, interact, behave and perform at work enables us to notice a difference when something begins to change.

There are many possible reasons for these changes, such as an increase in pressure, a decrease or change in social support, bereavement, promotion, increased or different responsibilities, problems at home, boredom and illness.

Spotting these changes early is the key. Having done so, you then need to know what can be done and who would be the best person to do it.

Last, and perhaps the greatest challenge, is to be able to engage in a conversation with the affected employee in such a way as to encourage them to get help. An inappropriate or clumsy intervention will only result in denial that there is a problem, with the employee going to increasing lengths to cover up their problems as they get worse.

Training and support

Line managers play a vital role in stress management. Often they are in daily contact with employees and, even when they are managing remote workers, they will be the person with whom the employee has most contact.

They are, therefore, ideally placed to recognise signs and symptoms of stress earlier than anyone else in an organisation. If line managers can develop skills in understanding and the early recognition of stress, everyone will benefit.

However, few managers have been trained in these skills. This is a role where OH professionals can take a leading role. OH nursing advisers are well placed to provide training for HR and line managers, as well as being available to provide advice and guidance on a day-to-day basis. This guidance will include helping them to identify situations in which it would be appropriate to refer an employee for assessment and support.

This is best done using a team approach, discussing the situation and agreeing the form that any referral will take. This will ensure the organisation knows what is going on in cases where it has been established that an employee is experiencing problems.

The nursing adviser should be able to provide an initial assessment of the situation. In the case of workplace stress, this will involve answering the following questions:

• What pressures is the individual experiencing?
• What influence will their personality have on their response to these pressures?
• What coping skills do they have and how well developed are they?

In some cases, the nursing adviser will be able to provide appropriate support by giving information and advice. This could include:

• Assertiveness
• Bullying
• Diet
• Exercise
• Facing problems
• Identifying and using available support
• Information about employers’ policies
• Medical conditions
• Relaxation
• Time management

The nursing adviser can also play a role in ‘signposting’ – identifying where more specialist advice and information is required. Examples of such areas include alcohol and drug problems, childcare and eldercare issues, financial problems and legal problems.

In this case, the task is to identify the underlying problem behind the symptoms. For example, a financial problem may be precipitated by the breakdown of a relationship that, in turn, was caused by an alcohol problem. Poor timekeeping may be caused by problems at home – such as difficulty with childcare arrangements.

In other cases, this will require an assessment by a psychologist or appropriately trained counsellor.

The role played by the OH adviser is to be the professional located within the employing organisation who decides that a particular individual needs specialist help. The nursing adviser may then make a referral or may recommend this course of action to the HR or line manager.

One of the reasons why EAPs have become increasingly popular in the UK in recent years is because they are able to offer a range of support for individuals experiencing problems (usually through a single point of contact), they are free to the user and they are confidential.

Referring

EAPs will usually offer self-referrals and will also offer the facility for management referrals.

The UK Employee Assistance Professionals Association (UK EAPA) Standards of Practice and Professional Guidelines for Employee Assistance Programmes 2000 lists the core delivery elements of an EAP, including ‘consultation for individual managers and the facility to make employee referrals’.

In practice, referrals to EAPs happen like this:

Self
The employee recognises they have a problem and that the EAP is able to offer support and guidance. They know how to contact the service and are comfortable enough to make a telephone call to ask for help. And they do so.

Informal
The employee may not have recognised or accepted that they have a problem, but someone else has brought it to their attention. The situation is under control but serious enough to warrant an intervention by a line manager, personnel/ HR, or the OH professional.

Their intervention will do two things – first, enable the employee to recognise they have a problem that is unlikely to disappear without specialist help and, second, motivate the person to ask for help. And they do so.

Formal
The employee will not recognise or accept that they have a problem. Informal approaches have been attempted but failed. The situation is not under control. There may be a risk to the safety of the employee or others – for example, an employee who drives a company vehicle and is unable to do so safely. Performance at work is impaired to the extent that disciplinary action and, possibly, dismissal is inevitable unless something changes.

The line manager, personnel or HR manager or OH professional formally interviews the employee and explains:

• What the problem is – performance
• What evidence the employer has to support this claim – attendance, behaviour, timekeeping, mistakes, failures etc
• What changes the employer needs to see to improve the situation and within what timescale.

A discussion then needs to take place between the employee and the referring manager to confirm they have a common understanding of the problem and the urgency involved.

The employee agrees they need help to address the situation. The employer explains they need tangible evidence that the employee is seeking help.

There is an agreement that the employee would benefit from contacting the EAP, is prepared to do so and will provide written consent for feedback to be given to the employer.

The referring manager calls the EAP and gives details of the formal referral. They agree that the EAP will advise whether or not the employee has made contact with the service within a specified time – usually one week.

The referring manager confirms this call has been made and that the employee is expected to contact the EAP within one week. And they do so (or if not, the employer may begin disciplinary proceedings or consider dismissal).

Advice on referrals

EAPs will usually provide a support service for referring managers. This is designed to help identify where a referral may be appropriate, and to talk through the process and possible outcomes. Encouraging employees to get help can be difficult and an interview – formal or informal – will make both parties anxious and needs to be managed professionally, ethically and appropriately. The support service will help coach the referrer through this process.

Confidentiality

To be effective, the EAP must be confidential. UK EAPA provides standards on confidentiality to which registered EAPs must comply.

Summary

OH plays a vital role in stress management. This role includes three components: assessment, treatment and referral.

Assessment may be conducted by line managers, HR managers or the OH department. Where it is not the OH department, they can train and support non-medical colleagues to intervene.

Treatment may be provided by OH directly, but OH advisers must recognise boundaries and their limitations.

OH advisers are often the most appropriate gatekeepers for onward referrals for specialist treatment.

Tim Cuthell is corporate support services manager for AXA PPP Healthcare

www.eapa.org.uk – The professional advisory association for EAPs – UK Employee Assistance Professionals Association (UK EAPA) – publishes standards of practice and professional guidelines for EAPs

Identifying stress