Alcohol Problem Intervention in the Workplace: Employee Assistance Programs and Strategic Alternatives

Alcohol Problem Intervention in the Workplace

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Alcohol Problem Intervention in the Workplace Employee Assistance Programs and Strategic and Strategic Alternatives Alternatives Edited by

Paul M. Roman

Q

Quorum Books Quorum Books New York • Westport, Connecticut • London

Library of Congress Cataloging-in-Publication Data Alcohol problem intervention in the workplace : employee assistance programs and strategic alternatives / edited by Paul M. Roman, p. cm. Includes revisions of many of the papers presented at a conference entitled "Alcohol and the Workplace: Integrating Perspectives on Prevention and Intervention" held May 21-24, 1988 at the Jekyll Island Club, Jekyll Island, Ga., together with others prepared subsequent to the conference. ISBN 0-89930-459-1 (lib. bdg. : alk. paper) 1. Alcoholism and employment—Congresses. 2. Employee assistance programs—Congresses. I. Roman, Paul M. HG174.K47 1990 332.1—dc20 89-27239 British Library Cataloguing in Publication Data is available. Copyright © 1990 by Paul M. Roman All rights reserved. No portion of this book may be reproduced, by any process or technique, without the express written consent of the publisher. Library of Congress Catalog Card Number: 89-27239 ISBN: 0-89930-459-1 First published in 1990 Quorum Books, 88 Post Road West, Westport, CT 06881 An imprint of Greenwood Publishing Group, Inc. Printed in the United States of America

The paper used in this book complies with the Permanent Paper Standard issued by the National Information Standards Organization (Z39.48-1984). 10 9 8 7 6 5 4 3 2 1

To Donald F. Godwin: Pioneer, Leader, Supporter, and Friend of Research on Alcohol Problems and the Workplace

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CONTENTS Illustrations

xi

Preface

xv

1. The Salience of Alcohol Problems in the Work Setting: Introduction and Overview PAUL M. ROMAN

1

Part I The Social and Organizational Contexts of

Alcohol Problems in the Workplace 2. The Impact of Macrosocial Forces on the Distribution of Alcohol Problems in the Workplace DAVID J. PITTMAN 3. Employed Adults at Risk for Diminished Self-Control over Alcohol Use: The Alienated, the Burned Out, and the Unchallenged DOUGLAS A. PARKER and GAIL C. FARMER 4. Jobs, Occupations, and Patterns of Alcohol Consumption: A Review of Literature JACK K. MARTIN

19

27

45

Contents

viii 5. Microsocial Processes Impacting on Alcohol Problems over Work Careers

67

JUDITH A. RICHMAN 6. Occupational Drinking Subcultures: An Exploratory Epidemiological Study

77

KAYE MIDDLETON FILLMORE 7. Drinking, Social Networks, and the Workplace: Results of an Environmentally Focused Study

95

GENEVIEVE AMES and CRAIG JANES 8. Business and Professional Women: Primary Prevention for New Role Incumbents

113

ELSIE R. SHORE 9. The Extent and Patterning of Job-Related Drinking Problems

125

HAROLD A. MULFORD

Part II Employee Assistance Programs and Related Strategies: Structure, Dynamics, and Problems 10. Employee Assistance Programs: Utilization and Referral Data, Performance Management, and Prevention Concepts

143

TERRY C. BLUM and NATHAN BENNETT 11. Health Promotion Programs and the Prevention of Alcohol Abuse: Forging a Link

163

MARTIN SHAIN 12. Expanding the Role of EAPs into Primary Prevention: The EAP as Organizational Consultant

181

WALTER REICHMAN and FRANK GUGLIELMO 13. EAPs and Early Intervention: Maximizing the Opportunities BRADLEY GOOGINS

191

Contents 14. The Bystander-Equity Model of Supervisory Helping Behavior: Past and Future Research on the Prevention of Employee Problems LAWRENCE H. GERSTEIN 15. EAPs and Early Intervention for Alcohol Problems at the Workplace ANDREA FOOTE 16. Help-Seeking and Helping Processes within the Workplace: Assisting Alcoholic and Other Troubled Employees

ix

203

227

237

WILLIAM J. SONNENSTUHL 17. Workplace Influences on Attitudes about Alcoholism

261

JANET S. MOORE 18. EAP and Wellness Program Follow-up as Primary, Secondary, and Tertiary Prevention Strategies in the Workplace

277

JOHN C. ERFURT 19. A Systematic Approach to the Evaluation of Employee Assistance Programs: A Conceptual Analysis

297

LINDA F. PATRICK 20. Alcoholism Treatment Providers and the Workplace LISA K. BLOCK 21. Alcoholism Treatment Programs and the Worksite: Sources of Conflict—The Need for Cooperation WILLIAM J. FILSTEAD

315

327

Part HI Practical Implications of Strategic Alternatives in Dealing with Alcohol Problems in the Workplace 22. Implications for Intervention and Prevention in Three Streams of EAP-Related Research HARRISON M. TRICE

339

Contents

X

23. Prevention of Alcohol Problems in the Workplace: A Public Policy Perspective HAROLD D. HOLDER 24. Strategic Considerations in Designing Interventions to Deal with Alcohol Problems in the Workplace

361

371

PAUL M. ROMAN Index

407

About the Contributors

411

ILLUSTRATIONS FIGURES 10-1

Core Technology and Functions of Employee Assistance Programs 10-2 Personnel/Human Resource System 19-1 Documents Model of an EAP

145 154 310

TABLES 3-1 3-2

6-1 6-2

6-3

Correlations of Alienation Variables with Other Variables among Employed Men and Women Adjusted Mean Scores for Problematic and Impaired Control by Substantive Complexity, Powerlessness, and SelfEstrangement Occupations within Social Strata by Workplace Factors Hypothesized to Differentiate between Them Frequency of Drinking and Drunkenness, Socializing with Colleagues, Drinking with Colleagues, Leisure Time Activities, and Attitudes toward Drinking for Technicians and Sales Representatives

84

Frequency of Drinking and Drunkenness, Socializing with Colleagues, Drinking with Colleagues, Leisure Time Activities, and Attitudes toward Drinking for Recording Clerks and Protective Service Workers

87

34

36 81

xii 6- 4

8- 1 8- 2 8-3 8- 4 8-5 9- 1 9 2 99- 3

Illustrations Frequency of Drinking and Drunkenness, Socializing with Colleagues, Drinking with Colleagues, Leisure Time Activities, and Attitudes toward Drinking for Food Handlers and Truck Drivers Quantity-Frequency of Alcohol Consumption, Sample 1 Quantity-Frequency of Alcohol Consumption, Sample 2, Women Only Negative Consequences of Alcohol Use Some Negative Consequences Related to On-the-Job Drinking Reactions to Business Drinking Vignettes Subscales of the Iowa Alcoholic Stages Index Job-Based Problem Drinking among Employed Problem Drinkers, General Population, Iowa, 1979 Employed and Unemployed Problem Drinkers by Alcoholic Stages Index Scores, General Population, Iowa, 1979

90 115 116 117 119 120 127 130 131

9-4

Years Since First Occurrence of Selected Deviant Drinking Behaviors, Clinic Alcoholics, Iowa, 1966-1969 10- 1 Relationship between Company Size and EAP Presence 11-1

Prevalence of HPP Components in Seven Studies Concern about Drinking and Other Health-Related Concerns 11-3 EAP Practitioner Perceptions of Value of HPPs in Prevention of Alcohol Abuse and Characteristics of Their Organizations, in the Toronto Area

11-2

15-1

133 148 165 169

173

Prevention/Intervention Paradigm 15- 2 Stage of Problem by Type of Problem 15- 3 Source of Referral by Work Performance Problem 17- 1 Percentage of Supervisors Who Were Accepting of the Alcoholic and Supportive of Alcoholism Programs by Classification of Problem Drinking

272

18- 1

279

Health Service Follow-up

18- 2

228 230 231

Definitions of Primary, Secondary, and Tertiary Prevention 18-3 Follow-up as a Method of Primary, Secondary, and Tertiary Prevention

280 280

18-4

The Impact of Follow-up on Blood Pressure Control

282

18- 5

The Impact of Follow-up on Wellness Program Participation (Weight Loss and Smoking Cessation)

283

Illustrations 18-6 18-7 18-8 18-9

18-10 18-11

18-12

21-1

xiii

The Impact of Follow-up on Cardiovascular Morbidity and Mortality The Impact of Follow-up on EAP Clients (Substance Abusers) Long-Range Follow-up and Tracking of EAP Clients in One Large Company, on the Basis of Health Care Claims Major Organizational Change in Both Basic EAP Structure and Policy Regarding the Utilization of Substance-Abuse Treatment Benefits The Relationship between Wellness Variables (Blood Pressure and Smoking) and Alcohol Consumption The Relationship between Hypertension (High Blood Pressure) and a Major Work Performance Measure (Absenteeism) The Relationship between Two Wellness Variables (High Blood Pressure and Smoking) and Health Care Costs and Disability Costs

294

Trends in Alcoholism Beds and Services

330

284 285 287

288 293

294

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PREFACE The serious attention of social scientists to the relationships between alcohol and work can be traced back at least to the 1950s, with shadows of such an interest evident even earlier. As is true with much of the work in alcohol studies, the research focus on alcohol/work has been heavily concerned with a variety of practical issues. As a consequence, researchers in this specialty have typically had extensive ongoing interactions with practitioners, including both workplace program managers and external providers of alcoholism treatment and related services. The mutual concerns emerging from these interactions include the refinement of strategies for identifying and providing assistance to employed alcoholics and problem drinkers, as well as a more cautious interest in investigating the relationship between workplace factors and the development of excessive drinking and alcoholism. This work was nascent during the 1960s but was considerably enhanced with the founding in 1970 of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). This federal agency provided mechanisms for promotion of workplace interest in dealing constructively with alcohol problems and provided funding for both research and demonstration projects focused on the workplace throughout the 1970s. Changes in federal policy has led in the 1980s to a narrowing of available funding to scientific research and elimination of demonstration project support. While the researchers working on these topics have been relatively few in number, they have sustained a lively interest in alcohol/work nexus and have endeavored to attract others to this research area. One of the mechanisms for sustaining the interest and interaction of applied researchers has been the faceto-face conference where ideas and research strategies can be shared, with an eye toward stimulating and refining further research as well as attracting the interest of other researchers.

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Preface

For the reader desiring exposure to the breadth of issues that have emerged from research on alcohol and the workplace, a review of the publications emerging from the conferences of alcohol/work researchers over the past decade may be of value. The first such conference, held in Reston, Virginia, in May 1980, resulted in an extensive volume of research papers and agendas for suggested future research (NIAAA, 1982). The conference was comprehensive in scope, with the research presentations more or less tempered by reactions to the empirical work by both practitioners and other researchers who had not had extensive involvement in research on alcohol and the workplace. A second conference was held in Washington, D.C., in 1984 under the auspices of the NIAAA's parent agency, the Alcohol, Drug Abuse and Mental Health Administration. This conference had several goals, including the broad consideration of the possible integration of research at the worksite focused on alcohol, drug abuse and psychiatric disorders, a review of issues in research methodology peculiar to research which requires worksite access and cooperation, and the steps necessary to maintain a constructive dialogue between the interests of researchers and the data-based needs of practitioners. The meetings resulted in an extensive volume of published proceedings (Godwin, Lieberman, and Leukefeld, 1985). A third conference, sponsored through a grant from NIAAA to the Boston University Graduate School of Social Work, was held in Elkridge, Maryland, in March 1985. The participants in this event were balanced equally between researchers and practitioners. The conference included discussions of employee assistance program (EAP) boundaries, workplace integration of intervention efforts, and cost containment issues, with summaries of the proceedings subsequently published (Grimes, 1986; Googins, 1986). These government-sponsored conferences have not however been the only research forums about alcohol and the workplace. For several years, the Southeastern Employee Assistance Program Institute sponsored conferences of researchers as part of its annual week-long training sessions for practitioners. Two of these conferences resulted in publications of research papers (Grimes, 1984, 1987). Since its earliest days, the Employee Assistance Professionals' Association (EAPA, formerly ALMACA, the Association of Labor and Management Administrators and Consultants on Alcoholism) has had a research committee that has met at least once a year to exchange ideas. In 1987, 1988, and 1989 the association published the papers that were presented in the research track of its annual meetings. In June 1987, the Extension Division of the University of California, San Diego, sponsored a conference for researchers and practitioners entitled, "Alcohol Problems in the Workplace: Beyond Employee Assistance." This event brought together researchers interested in both primary and secondary prevention strategies for dealing with alcohol problems at the worksite (Colthurst, 1987). Indeed, it was at an after-hours meeting in a motel room during that conference that a number of the participants in this volume gathered and "hatched" the

Preface

xvii

idea for bringing together a broader based group that could place alcohol-related employee assistance issues in a broader perspective. Much of the contents of the present volume comprises revisions of papers presented at a conference entitled "Alcohol and the Workplace: Integrating Perspectives on Prevention and Intervention," held May 21-24, 1988, at the Jekyll Island Club, Jekyll Island, Georgia. The conference, hosted by the Institute for Behavioral Research of the University of Georgia, was funded through Grant No. R01-AA-07218, awarded to the University of Georgia by the National Institute on Alcohol Abuse and Alcoholism, Paul M. Roman, principal investigator, and Terry C. Blum, co-principal investigator. This volume is considerably more than a proceedings of that conference; it includes several chapters prepared subsequent to the conference and does not include the papers by several conferees whose schedules prevented them from completing chapters for inclusion in this publication. This conference differed from the earlier alcohol/workplace conferences in that it was limited to researchers. This volume, however, directed toward both practitioners and researchers, provides a wide range of new data and new ideas about strategic options related to coping with alcohol problems in the workplace. The conference and this volume would not have been possible without the supportive cooperation and assistance of Donald F. Godwin of the Prevention Research Branch, NIAAA, to whom this work is gratefully and affectionately dedicated. Don's distinguished career has covered practically all aspects of the alcohol/work connection. Throughout the 1970s he was chief of the Occupational Programs Branch of the NIAAA. He and his staff were responsible for developing and monitoring a wide series of demonstration initiatives focused on delivering alcoholism services to working people in all walks of American life. As one views the tremendous growth of constructive efforts made to deal with alcohol problems in the workplace that has occurred over the past twenty years, one can discern multiple routes contributing to the vigor of the contemporary scene that can be traced back to the efforts of Don, his staff, and the NIAAA. Throughout all of this time, Don has been a tremendous supporter and advocate of research on alcohol and the workplace. Others who offered their support for the conference and this resulting publication include Lois R. Chatham, Ph.D., retired director of the Division of Basic Research; Albert A. Pawlowski, Ph.D., retired associate director of the Division of Basic Research; John Noble, currently director of the Epidemiology Research Unit of the Division of Intramural Research; and Enoch Gordis, M.D., Institute director—all of the NIAAA. Additionally, David Pittman, Ph.D., Department of Sociology, Washington University, and Jan Howard, Ph.D., chief of the Prevention Research Branch, NIAAA, gave generously of their time and expertise at a preconference planning session in Atlanta in February 1988. Finally, the conference would not have been possible without the excellent planning abilities and diplomatic skills of Lisa Block of the Institute for Behavioral Research, University of Georgia. Practically no one who attended the conference

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Preface

could believe that we could enjoy such an elegant and first-class facility and yet stay within the state-imposed expense limits! The publication of this volume would not have been possible without the enthusiastic and patient support of Tom Gannon of Quorum Books. The editorial work of Arlene Belzer enhanced the quality of the work and the accuracy of the bibliography. The index was carefully prepared by Teresa Doane. Myra Bean performed many duties as a continuing top-notch administrative secretary and as a buffer for my missed deadlines. My collaborator and spouse, Terry Blum, has been patient and supportive throughout. With this heart full of thanks, I am supposed to warn the reader that any remaining errors are my own, my very own, fault.

REFERENCES Colthurst, T. (1987). Proceedings of the conference on alcohol problems in the workplace: Beyond employee assistance. La Jolla, CA: Regents of the University of California. Godwin, D. F., Lieberman, M. L., and Leukefeld, C. G. (Eds.). (1985). The business of doing worksite research. Rockville, MD: Alcohol, Drug Abuse and Mental Health Administration, U.S. Public Health Service. Googins, Bradley. (1986). EAPs and cost containment. The Almacan, 16 (11), 18-19. Grimes, C.H. (1984). EAP research; Volume I. Troy, MI: Performance Resource Press. Grimes, C.H. (1986). At Elkridge: A discussion of EAP objectives. The Almacan, 16 (12), 16-21. Grimes, C.H. (1987). EAP research: Volume II. Troy, MI: Performance Resource Press. National Institute on Alcohol Abuse and Alcoholism. (1982). Occupational alcoholism: A review of research issues. (DHHS Publication No. [ADM] 82-1184). Washington, DC: U.S. Government Printing Office.

1 THE SALIENCE OF ALCOHOL PROBLEMS IN THE WORK SETTING: INTRODUCTION AND OVERVIEW PAUL M. ROMAN

As we enter the final decade of the twentieth century, there is a consensus throughout American society that we are experiencing severe problems with the abuse of alcohol and other drugs. Such concern is not limited to our national boundaries but is truly a set of international issues, believed to impact economic, social, and individual welfare throughout the world. One does not have to look far to see the extent of governmental activity, both in the United States and throughout the world, directed toward combatting the distribution and use of illegal drugs. Nonetheless, alcohol consumption far outruns the consumption of any other addictive and seriously psychoactive substance. It has been argued that the experience with national prohibition in the United States led to a marked withdrawal of significant governmental involvement in dealing with the consequences of alcohol abuse; ironically, many experiences with national prohibition are now being repeated with illegal drugs. For present concerns, it is important to emphasize the extent to which efforts to deal with America's alcohol problems have been privatized since the 1930s. To a very considerable extent, the responsibility for dealing with alcohol problems is in the hands of workplaces, families, and communities, a dilemma that is not often appreciated in discussions of alcohol abuse. The purpose of this volume is to provide both practitioners and researchers with a comprehensive overview of current research and thinking on one set of societal actors on whom this responsibility has been placed: the various sectors of the American workplace. The relationship between alcohol and the workplace has emerged during the past decade as a significant issue for policymakers, researchers, practitioners, and organizational decisionmakers. Our focus is on the broad interface between alcohol problems and work; specific attention is

2

Alcohol Problem Intervention in the Workplace

given to intervention strategies based in the workplace to deal with the impact of alcohol consumption on employment and organizational behavior. The volume deals only tangentially with alcohol issues other than those involving work and the workplace and only incidentally touches upon issues involving drugs other than alcohol. While there is considerable agreement that alcohol possesses pharmacological properties that produce effects parallel to those of drugs such as cocaine, marijuana, and even the opiates, there are a number of dramatic sociological differences between alcohol and other drugs that justify separation of alcohol and other drug issues. 1. The use and abuse of alcohol are far more widespread than the use and abuse of other drugs. 2. These use patterns reflect the status of alcohol in American society as a legal beverage, and governments receive considerable tax revenue from control mechanisms focused on the manufacture and distribution of beverage alcohol. By permitting and taxing alcohol distribution and use, the government tacitly allows alcohol use as a public right and privilege and tacitly regards most alcohol consumption as a behavior that is not harmful to the majority of drinkers. 3. In very sharp contrast to the War on Drugs, the principal societal reaction toward nonalcoholic drugs evident at the present time, American society has attempted and rejected national prohibition as a means for dealing with alcohol problems. 4. The nature of legal controls essentially facilitates alcohol use in American society. A small proportion of the American population resides in counties that are "dry" in terms of the availability of alcoholic beverages. Beyond these various localized and rare instances of prohibition, the legal structures affecting alcoholic beverage use may be viewed as remarkably minimal. The vast majority of Americans live in settings where the minimal rules and laws about alcoholic beverage consumption center on (1) age requirements to purchase alcohol legally; (2) times during which alcoholic beverages can be purchased; (3) restrictions on the location and licensing of distribution centers; (4) rules and norms proscribing the consumption of alcohol in certain settings (e.g., schools, certain public entertainment centers, on the street, in moving automobiles, in churches, and in most workplaces); and (5) definitions of blood alcohol levels of individuals who may legally operate motor vehicles. Indeed, if one considers the effects of this catalog of legal structures in terms of their significant impact on opportunities to drink, it is clear that only the first and last sets of rules are of any real social significance. 5. In addition to the weak set of legal proscriptions, American culture accepts and "normalizes" the use of alcohol in a wide variety of settings (e.g., cocktail and "happy" hours at the close of the workday; such ceremonies as weddings, baptisms, and funerals; common mealtime consumption of beer and wine; and holidays) without penalty and often with strong encouragement and facilitation of use. 6. Given the above facts, it is clear that there is little societal consensus on the dividing lines between alcohol use and alcohol abuse, between legitimate and illegitimate occasions for drinking, and between the careers of "social drinkers" and persons who might be labeled as "alcoholics." What is the nature of America's alcohol problem? An answer to such a question could easily consume an entire volume. Our purpose here is to focus upon aspects

Introduction a n d Overview

3

of solutions to the problem in the workplace setting rather than to deal extensively with a societal-level definition of the problem. Nonetheless, it is useful to point to the multitude of forms of alcohol problems in this society, sometimes summarized as a set of massive social costs that can be classified into at least five categories: 1. Social disruption owing to accidents, crime, ill health, lost jobs, and interpersonal deviance resulting from alcohol abuse 2. Premature death caused by illness or injury related to alcohol abuse 3. Lost productivity in both the immediate term because of impaired performance and over the long term because of deteriorating careers and abilities to function, the latter relating back to premature death and disability 4. Costs of the social control efforts that are devoted to combatting these consequences as well as costs of intervention efforts that attempt to rehabilitate those who have become chronic alcohol abusers 5. Deterioration in overall societal morale as a result of the insidious consequences of alcohol abuse on individuals, families, communities, and workplaces From this list it is clear that employers have substantial vested interests in dealing with alcohol problems. This is especially true in the United States where employers must deal with the direct effects of alcohol abuse on productivity. Further, employers also have become heavily responsible for providing the means for the treatment and rehabilitation of employees with alcohol problems as well as the myriad of other health problems that affect productivity and work careers. One strategy that has become particularly prominent in the workplace is the employee assistance program (EAP). Much of the material in this book is focused upon EAP issues. EAPs are not however the only means that employers have to deal with the impact of alcohol problems in the workplace. Other possible ways in which the workplace can become involved in dealing with the use and abuse of alcohol include the following: 1. Alcohol education for employees. 2. Alcohol-oriented policies such as restricting the availability of alcohol at company business and social functions, the reimbursement for alcohol consumption as an employee expense, and the availability of alcohol on company premises. 3. Fitness for duty policy prescribing punitive actions to be taken when employee alcohol consumption on the job is detected. 4. Corporate social responsibility in the community such as donations to the United Way for activities that deal with alcohol problems. This includes funding for treatment centers, for youth education, and for such local campaigns as BADD (Business against Drunk Driving). 5. Health promotion programs, which can include physical fitness, which may motivate persons away from the deleterious effects of social drinking in favor of other recreational activities. Companies' promotion of sports events which involve employees

4

Alcohol Problem Intervention in the Workplace

in team sports might be seen as a possible preventive strategy which relates to health promotion. Health promotion and wellness programs might also include the use of health risk appraisals to inform individuals of the deleterious effects of drinking. Such programs may also include measures of cholesterol and blood pressure levels, which are correlated with excessive drinking. Presentation of these health-related data to the employee may be a means of encouraging temperance or abstinence. Health promotion/ wellness programs are however highly variable in the extent to which they provide counseling and advice after obtaining measurements about health correlates of drinking behavior. 6. Health insurance coverage for alcohol problem treatment for the employee and employee dependents. The development and implementation of managed health care strategies, including participation in business roundtables to deal with health care issues, are part of this alternative. Related mechanisms allow for gatekeeping and counseling for employees and their dependents regarding the nature of alcohol problem treatment that is available through their health insurance policy coverage. Related to this is the extent to which the organization actively encourages the availability of alcoholism treatment services within Health Maintenance Organizations (HMOs) that are used as alternatives to employee health insurance coverage. 7. Inclusion of alcohol-abuse screening in drug-screening programs. 8. Safety-oriented programs which emphasize drinking behavior as deleterious to safety. FORCES INFLUENCING THE ADOPTION OF WORKPLACE ALCOHOL-RELATED INTERVENTIONS Relatively few attempts have been made to explain employers' interests in dealing with employees' alcohol problems or other instances of substance abuse and personal problems. There is a tendency toward viewing these programmatic introductions as reflecting either humanitarian demonstrations of corporate social responsibility or employers' cynical motivations to increase their control over their employees' behavior only to enhance productivity and organizational stability. Three major sociocultural trends of the past century in the environment surrounding U.S. work organizations support the diffusion of employers' active efforts to deal with any personal behavior of employees that might impinge on their job performances. First, technological changes increase the impact of the personally troubled employee, not only on individual productivity but also on the work and welfare of others both within and outside the organization. Second, the "medicalization" of behavioral problems within the larger culture is reflected in societal attitudes that have transformed many instances of "badness" into "sickness" (Roman, 1980). Associated with and influencing these attitudes is a rapid increase in the numbers of service providers which are marketing services to deal with these problems. Third, legal changes have undermined the common-law "employment at will" doctrine. Employers have generally lost their former prerogatives to dismiss any

Introduction and Overview

5

employee for any reason at any time. These complex legal changes, coming from multiple and varied sources, are coupled in many employers' perceptions with the manifold possibilities of employee-generated litigation. Together these changes appear to be moving toward requiring that employers provide opportunities for treatment for employees with behavioral disorders (see, for example, Denenberg and Denenberg, 1983). Several other, less visible, factors have considerable importance in explaining the emergence of employers' actions to deal with alcohol issues in the workplace. First, the changes that took place in the work force during the 1970s greatly increased the participation of ethnic minorities and of women in the workplace. The entry of large numbers of ethnic minority workers has sharply reduced the cultural homogeneity of work environments. To an unknown extent, these changes may have increased perceived needs for control of the work force, but it is difficult to separate such forces from changes in the regulatory environment that have attempted to ensure the equitable treatment in hiring and promotions of minority group members in the workplace. These speculations are offered some credence by the historical observation that various forms of "welfare capitalism" (programs designed to alter or improve the lives and lifestyles of workers) were especially prominent during the period (1880-1920) when very large numbers of non-English-speaking immigrants were entering the American work force (Brandes, 1976). The entry of very large numbers of women workers has altered work cultures in a different manner, intermingling the social needs of the workplace with those of families. In large part because of childbearing and childrearing decisions and responsibilities, women's motivations for work and career patterns are often different from those of men. Despite some degree of change in the division of labor in dealing with household responsibilities, such issues as child care and the care of other household dependents have become much more visible and critical in the workplace. Dealing with conflicts between work and family demands produces needs for support within the workplace, some of which may be met through comprehensive counseling programs such as EAPs. Such problems may also contribute indirectly to the development of alcohol-related issues which may surface at work. At a more macroscopic level, a new and complex relationship has emerged between the institutions of work and the family, which are intermingled with other forces that are increasing the interest in and involvement of employers with details of their employees' lives that extend well beyond the simplistic pragmatism of "getting the work out." In attempting to understand workplace motives in dealing with alcohol abuse, one other, newly emerging phenomenon deserves mention. Since the 1930s, a considerable degree of organizational effort has been directed toward the medicalization of alcohol problems and the social relocation of this culture's principal alcohol problems from the substance, alcohol, to the disease of alcoholism. Within this paradigm, "alcohol abuse" is generally but vaguely distinguished

6

Alcohol Problem Intervention in the Workplace

from alcoholism, and it is commonly dealt with through parallel therapeutic regimens that advocate abstinence as the solution. Recently, a small social movement, labeled "The New Temperance Movement," has emerged—one which focuses on three related issues: 1. The influence of the alcohol beverage industry on legislative decisions which, it is believed, is reflected in the relatively minimal taxation imposed on alcohol beverage sales. 2. The generally unregulated manner in which alcohol beverage advertising is directed toward the public, especially youth. 3. Data which indicate that, at the community level, alcohol problems are positively correlated with alcohol consumption. The interests of this movement also include attention to the health consequences of "normal'' alcohol consumption and the overall effects of drinking on health care utilization. This movement encourages increasing taxation, establishing controls on advertising, and restricting consumption. Results of these efforts may be seen in the legislation of increased age limits for the legal purchase of alcohol and in the increased penalties associated with drinking and driving. Most recently, a result of this movement's concerns has been the federal legislation requiring warning labels on all containers of alcoholic beverages sold in the United States. It may be argued that although this movement does not directly attack the disease concept of alcoholism, it moves societal attention toward a different definition of the sources of and solutions for excessive drinking and its consequences. The extent to which this new movement will influence the character of workplace intervention efforts directed toward alcohol and alcohol problems remains to be seen and understood, but it definitely offers a set of information which may be influential in the workplace. AN OVERVIEW OF EAPs Since much of the material in this volume is based upon EAPs, it is important to provide some basic descriptive information about them at the outset. Considerably more detail is found about EAPs in Part II, and the reader's attention is drawn particularly to the outline of the core technology of EAPs that is provided in chapter 10. EAPs provide the workplace with a systematic means for dealing with personal problems that affect employees' job performance. Included in this array of personal problems is employee alcohol abuse. Based on a written policy statement, EAPs provide supervisors access to professional consultation in dealing with subordinates whose performance is affected by such problems. EAPs also provide for employee self-referral. The activities within EAPs include assessment of the clinical nature of employee problems, motivating the employee to seek help, selection of appropriate community resources to treat the employee, aid in ac-

Introduction and Overview

7

cessing such services, follow-up of the employee at the workplace following service use, and the availability of training and consultation to supervisors and managers about the appropriate use of the policy and procedures. EAPs are directly descended from the industrial alcoholism programs that enjoyed a modest degree of adoption from the early 1940s through the 1960s (Trice and Schonbrunn, 1981). The issues of employee alcohol abuse and alcoholism remain prominent although rarely exclusive in today's EAPs. In very broad terms, research evidence (Blum and Roman, 1989) indicates that about one-third of EAP caseloads comprise employees with alcohol problems. In terms of the very general outcome criterion of the employee's being back on the job performing adequately at 12 months after the original referral to the EAP, data indicate that close to 70 percent of employees with alcohol problems are "successful" users of EAP services (Blum and Roman, 1989). The growth of EAPs, including their emphasis on alcohol problems, stems in part from a major federal effort in the early and mid-1970s to diffuse EAPs. The National Institute on Alcohol Abuse and Alcoholism (NIAAA), as part of an effort to mainstream alcohol problems into the health care system (Roman and Blum, 1987), supported consultation services directed at workplaces across the nation. In its review of the experience of the relatively few companies that had implemented industrial alcoholism programs, the NIAAA was the original advocate for the broad employee assistance program model within which efforts to deal with employee alcohol problems were embedded. It was believed that these earlier programs had enjoyed limited success because of their emphasis on alcoholism and supervisory identification of alcohol problems. NIAAA planners suggested that a broader program design focused on a range of employee problems would be more palatable to employers than one focused exclusively on a stigmatized condition, the seriousness of which managers would readily deny in their organizations. As is detailed below, the broader model also attempted to take supervisors out of a diagnostic role in the identification process and to emphasize instead the supervisors' responsibility for identifying job performance problems among their subordinates. Here it was assumed that supervisors could sidestep the denial efforts of the alcohol-abusing employee while at the same time fulfill their assigned responsibility for dealing with performance problems among their subordinates (Roman, 1988). American workplaces have adopted EAPs at a very rapid rate since the mid1970s. The patterns of these, described in chapter 10, indicate that the redesign of programs to the broader EAP model was an effective strategy, for it is clear that the industrial alcoholism program model had not diffused widely by the early 1970s (Trice and Schonbrunn, 1981; Roman, 1981). In line with the stated assertion that dealing with alcohol problems in American society relies largely on private sector initiatives, it is important to emphasize that the growth of EAPs in the private sector has occurred in a context of voluntarism. Although utilities operating nuclear power plants and some sectors

8

Alcohol Problem Intervention in the Workplace

of the transportation industry have been specifically mandated by the federal government to implement some form of EAPs, the remainder of the adoption has occurred in the context of voluntarism. The consequence of this voluntarism most visible to researchers investigating EAPs is the vagueness of boundaries around the definition of what constitutes an EAP. Efforts range from professionally staffed internal programs integrated into the personnel/human resource management (P/HRM) function to "hot line" telephone numbers publicized to employees which they may use to seek confidential assistance for personally defined problems. In some settings EAPs are found to be intermingled with wellness, stress management, and drug-testing programs. Thus although workplaces may have several different efforts directed toward dealing with employee alcohol and drug abuse, rarely are these efforts closely coordinated. Perhaps underlying the problem of coordinating multiple efforts is the vagueness in definition and the absence of consensual standards of what constitutes an EAP. This in turn raises special difficulties in defining the characteristics and predictors of EAP quality. Other than the macroscopic factors described above, organization-level motives surrounding EAP adoption are mixed. In some instances it is clear that program adoption simply reflects conformity to what is seen as an emerging norm for up-to-date human resources management practices, with little attention given to program outcomes. In other workplaces, carefully designed systems for program evaluation are in place; some focus on the clinical features of program outcomes, others are primarily centered on the work-related characteristics of the employees who receive EAP services. The mixture of employer motives in EAP adoption is reflected in the very uneven pattern of implementation that can be observed across the population of EAPs as well as reflected in the absence of common criteria for program evaluation across EAPs. While one might argue that this is simply a part of the newness of the endeavor, which will be resolved with time, the absence of definitions of good programs may be creating major problems for the future if EAP professionals desire to bring existing EAPs up to some yet-unstated set of standards. TYPES OF EAPs The prototypical EAP is based within a work organization and staffed by an employee of that organization. This individual or unit functions as the professional resource to which self- or supervisory referrals are directed. In most instances the next step is an initial assessment followed by referral to a community resource, with the program coordinator minimizing his or her own counseling or treatment relationships with employees. This program design is to a considerable extent, although not totally, limited to larger work organizations. Program components typically include a written policy statement (developed jointly by management and labor in unionized organizations), training of supervisors and managers about program procedures, orientation of all company staff to the

Introduction and Overview

9

program's policies and details about what can be expected in instances of employee self-referral, a clearly identified phone number or office location where employees and supervisors can go for assistance, and health insurance coverage that provides all or at least substantial copayments for treatment for alcohol problems. Almost all programs also provide EAP services to employee dependents. The second type, the external program model, emerged during the 1970s. These programs are generally characterized by the presence of a formal contract with an external agency which provides most of the services for the assistance program, with the contract fee based on either the actual services provided or on the number of employees and the scope of services that are made available by the provider organization. Compared to internal programs, there is great variation in the structural ingredients of external programs and the extent of program services. At one end of the continuum are those that are identical to the full-scale internal program, with all components in place and a full-time program coordinator present, the distinction being that the coordinator is an employee of an external agency and the service commitment is based on a time-limited contract. At the other end of the spectrum are externally based programs visible only to the extent that they offer to employees a phone number which they can use should they perceive a need for program services; following such a contact, the service agency would at minimum provide an evaluative interview and offer a referral to community resources for appropriate assistance. There are various combinations of internal and external program designs; in one example, an external contractor places staff within a workplace on a fulltime basis to function in a fashion almost identical to that of an internal program staff. There are also settings in which coverage of a particular work force involves the combined efforts of internal staff and additional personnel who are employees of an externally contracted service provider. The data collected tend to show that internally based programs offer a greater emphasis on employee alcohol problems than externally contracted programs. This is a dangerous generalization, however, and the bottom line appears to lie in the extent to which a particular workplace's management stresses the importance of the EAP's attention to employee alcohol problems. Further, as with any externally contracted service, the emphases and quality of that service delivery are a direct function of the extent to which the contracting organization supervises and monitors the contractor's performance. Our own research indicates great variability in the extent to which companies provide such contract supervision and thus have control over the quality and direction of the EAP services that are delivered. Thus it is not safe to conclude that an internally based program will automatically generate greater emphasis on employee alcohol problems, but that such emphasis will vary by the extent to which decision-makers do or do not press for it. There is an additional and very important type of program about which there

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Alcohol Problem Intervention in the Workplace

is very little research data—the program that is based in a labor union or in a professional association where either union or association members share a common occupation. These programs appear to be widespread, yet there are no survey data that describe their prevalence, staffing, or case outcomes. Reports in the popular media attest to both the success of these programs and the enthusiasm with which they have been adopted by both unions and professional societies and associations. One ethnographic report (Sonnenstuhl and Trice, 1987) provides an excellent description of how such a program, which emerged in a local of the Tunnel Workers' Union, led to the development of a recovering alcoholic counterculture which has evidently altered the traditional heavy-drinking behaviors within this union's culture. Peer referral appears to be the dominant mode in these programs, and understanding its dynamics would contribute both to alcohol intervention efforts in the workplace and to the general knowledge about social interaction processes. FUNCTIONS AND GOALS OF EAPs Consistent with the opening discussion regarding the social and economic costs of alcohol problems in this society, it is clear that employers adopt such programs to reduce costs and to reduce the uncertainty that is associated with managing human resources. This does not mean however that employers use hard and fast bottom-line cost-savings as the basis for EAP adoption or maintenance. In our own program of research, we have identified five goals or functions of EAPs that are relevant to employee alcohol problems and which are the basis for EAP adoption and maintenance. Each of these functions subsumes a costbenefit rationale but does not always include a means for its direct measurement. Three of these we classify as management-related functions and two as employee benefits-related functions. The first management function is continuous with the earlier function associated with industrial alcoholism programs, namely, the retention of the employment of employees in whom the organization has a substantial training commitment, combined with recognition of the employee's commitment to the organization. This function is based upon the assumption that effective intervention strategies can be utilized to reduce or eliminate the job performance problems of employees with a substance-abuse problem and that the costly impact of turnover can be avoided in many instances. This function also has a humanitarian dimension in that the employer's willingness to afford employees rehabilitation opportunities recognizes the employees' commitment to the organization. These actions in turn reflect positively on the employer's image within the work force. A second management function has been articulated as EAPs' reducing or eliminating supervisory, managerial, and union officials' responsibility for counseling troubled employees (Roman, 1988). The assumption here is that, in the

Introduction and Overview

11

absence of an EAP, supervisors and managers have an implicit responsibility of attempting to deal with the troubled employee. Such an implicit responsibility is likely to be even more pronounced in the case of union representatives. Without policy guidelines or assistance from professional expertise, however, such counseling efforts will be notably inefficient. Thus the nature of this second function is to discourage supervisors, managers, and union shop stewards from attempting to counsel or treat the troubled employee but to encourage them to seek consultative assistance from an EAP specialist when it is evident that they are dealing with a troubled employee. The third management function is related to the legal protections that have developed around the employment setting, collective bargaining, and the work organization's own guidelines in the implementation of progressive discipline. This function is that the EAP policy provides for due process for those employees whose personal troubles may be affecting their work. The provision of offers of assistance for these employees is not only humanitarian, but may also protect the employer against subsequent legal action. At the same time, equitable implementation of the EAP policy fosters an atmosphere in which unions can work supportively with management in EAP implementation. The first of the two employee benefits-management functions associated with EAPs has gained great prominence recently: the implementation of efforts to control the employer's cost of employee health care usage. Evidence indicates that employees with alcohol problems are heavy users of health care services and that this heavy use pattern extends to their families as well (Fein, 1984; Holder and Hallan, 1986; Holder, 1987). Evidence indicates further that these levels of usage decline markedly following interventions to deal with the alcohol problems. Thus, while the initial investment in providing treatment for alcohol problems may appear to be high, follow-up studies indicate that these investments ultimately contain health care cost. Related but distinctively different is the role of EAPs in providing a gatekeeping function in an employee's use of health care services for substanceabuse problems. It is evident that many employees do not have access to criteria by which they can select the most effective providers for these services when they perceive they have a problem requiring such assistance. Advice and direction about such resource use by the EAP can result in more efficient use of more effective services, resulting in cost savings for the employer as well as for the employee when copayments are involved. This function is being extended in many organizations with EAPs through the establishment of preferred provider arrangements whereby community resources are evaluated in terms of both their effectiveness and their cost efficiency with both the employer and employee benefiting from direction to these services. With or without Preferred Provider Organization (PPO) arrangements, workplaces are rapidly moving toward the requirement of precertification of employees' use of inpatient substance-abuse services in order for the employee to minimize the copayment, or in some instances to eliminate the copayment altogether.

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Alcohol Problem Intervention in the Workplace

SUMMARY OF CONTENTS The material in this volume explores alternative strategies for dealing with alcohol problems in the workplace, with particular attention to EAPs. To a considerable extent, the authors approach EAPs from a critical perspective. This is represented in two ways: first by such authors as Martin Shain and Walter Reichman who have been "insiders" in terms of a heavy focus on EAPs in their research careers and second by such authors as Harold A. Mulford and Kaye Middleton Fillmore, "outsiders" who have had broader concerns with the social correlates of alcohol problems. Equally important are the chapters that place the alcohol/work nexus in larger and different contexts, directing attention to EAP alternatives, modifications of EAPs, or expansions of EAP strategies. It was the introduction of these different treatments of both data and approach that created the uniqueness and excitement in the conference where many of these materials were presented. The volume comprises three parts. Part I is concerned primarily with issues regarding the distribution and correlates to alcohol problems and alcohol use among employees. Part II is centered on issues associated with EAPs. Part III is a general conclusion and overview of EAPs and strategic alternatives. Part I begins with David J. Pittman's presentation of a general overview of some of the macrosocial trends in American culture and demography that affect the relationship between alcohol use and both the employees and the employment setting. Douglas A. Parker and Gail C. Farmer present an analysis of data from a sample of Detroit workers which focuses upon the occupational, career, and organizational factors that reduce workers' abilities to control their alcohol consumption. Jack K. Martin offers a more general review of the perspective that is the basis for the work of Parker and Farmer and then contrasts it with other studies that can be placed under the rubric of attempting to isolate the factors associated with work that may create settings conducive to excessive drinking through risks, stresses, or combinations of risks and stresses. This theme continues in Judith A. Richman's chapter, which reviews theoretical perspectives on the psychosocial etiology of alcohol problems and describes a research program that focuses on how these factors impinge upon drinking behavior among medical students. The level of analysis changes in the following two chapters to a concern with culture and work, broadly conceived. In a complex but rich descriptive analysis, Kaye Middleton Fillmore compares the relationship between occupational subcultures and drinking behaviors in three pairs of occupations, with social class common in each pair. In the preface to her chapter, Fillmore draws important distinctions between considerations of alcoholism, problem drinking, and drinking, all of which have differential salience to employers. She emphasizes the extent to which researchers in the alcohol/work specialty have tended to ignore drinking behaviors and have instead concentrated their efforts on problem drinking and alcoholism. This theme continues in the work of Genevieve Ames and

Introduction and Overview

13

Craig Janes, who also emphasize the importance of focusing on drinking and its various contexts rather than focusing exclusively on problem drinking or alcoholism. This chapter pays particular attention to on-the-job drinking, a phenomenon reported rarely in Fillmore's survey data. This difference highlights the variation in findings when different research methodologies are employed. Ames and Janes' work underlines the importance of the environmental context in facilitating and supporting drinking behaviors that may be costly and risky to both employers and employees. The theme of social and environmental factors continues in the chapter by Elsie R. Shore, which reports indepth survey data on the drinking behavior of employed women, with particular attention to the contexts in which it occurs and the apparent effect of employment on women's drinking patterns. The final chapter in Part I brings together several of the issues raised in the previous chapters and offers distinctive challenges to EAPs. Harold A. Mulford analyzes several data sets collected for different purposes as they bear upon the identification of drinking problems at work. He is not optimistic about the effectiveness of the EAP strategy for the early identification of employed problem drinkers. He offers suggestions for further research on this issue, but he remains critical of the assumptions underlying EAPs. His concluding observations consider alternative control strategies to deal more effectively with employed people with drinking problems. Part II opens with an overview discussion of EAPs by Terry C. Blum and Nathan Bennett; their chapter includes data-based summaries of current trends and patterns within EAPs that are pertinent to alcohol problem prevention issues. This is followed by three chapters which consider the possibilities of altering the configurations of EAPs so that their basic functions and preventive potential might be enhanced while simultaneously developing synergy through interfaces with other issues in the workplace. Martin Shain's chapter, which focuses on the potentials of alcohol problem prevention within the designs of EAPs and health promotion programs, provides the author with a foundation for advocating a greater degree of integration across the two apparently (but misleadingly) distinctive types of program intervention strategy. Following this theme, Walter Reichman and Frank Guglielmo discuss a project conducted with the New Jersey State Police in which they were impressed by the potential impact of expanding the role of the EAP to include an effort to deal with stress among police personnel. The theme of expanding the potential value of the EAP to both employees and the workplace continues in the chapter by Bradley Googins who describes his program of research related to the involvement of EAPs in dealing with issues stemming from conflicts in demands between work and family roles. Following are six chapters which have in common their focus on the effectiveness of mechanisms in the environment both internal and external to the organization in supporting the EAP's core technology. Lawrence H. Gerstein presents the results from a program of research dealing with the tendencies of supervisors to provide help to troubled subordinates and the content of the cues

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Alcohol Problem Intervention in the Workplace

that leads supervisors to take such actions. Gerstein's chapter includes suggestions for further research on identification and helping processes and discusses the means by which researchers from different disciplines can cooperate in studying the alcohol/work nexus. Following is Andrea Foote's chapter on the various dimensions and strategies relevant to the early identification of alcohol problems in the worksite. Foote provides an especially valuable discussion on the value of the distinctions between prevention and intervention strategies. The processes of identification are viewed in a different manner in the chapter by William J. Sonnenstuhl. His focus includes the social interaction networks that affect the decision of the individual to go to the EAP, and then he describes the actual help-giving processes that go on within different EAP settings. His qualitative research method both contrasts with and enriches the preceding chapters with quantitative approaches. Janet S. Moore reviews the attitudinal context in which EAPs function, pointing out the importance of attitudes toward alcoholism in effecting the referral process as well as in determining how the employee who is recovering from alcoholism will be received back into the workplace. Her analyses do not indicate strong impacts of EAPs' presence on attitudes toward alcoholism. In the following chapter, John C. Erfurt focuses upon an issue that is gaining prominence as the one needing the most attention in any health delivery attempt: follow-up of the client who has received the intervention. Erfurt discusses the follow-up processes associated with workplace programs and compares and contrasts the processes in EAPs and wellness programs. He presents extensive data that describe the outcomes and other consequences of implementing systems of follow-up. Linda F. Patrick considers the issues associated with evaluating EAPs, first developing distinctions between EAPs and other types of strategies which have been the typical subject of well-known program evaluation techniques. By delineating the various processes that occur within EAPs, Patrick presents a "documents" model as a suggested foundation for an evaluation model. The following two chapters are concerned with alcoholism treatment, one of the most vital and controversial issues associated with alcohol problem intervention in the workplace. Lisa K. Block's chapter offers data from a new research study which has focused on the organizational aspects of alcoholism treatment. She provides an overview description of findings about treatment center structure and then reviews the manner in which alcoholism treatment centers interface with the workplace and with employee assistance programs. William J. Filstead, who is a corporate officer in a major alcoholism treatment organization as well as a research sociologist, provides a valuable perspective on alcoholism treatment from the point of view of the treatment organization itself. Filstead's discussion sheds light on some of the conflicting aspects of the relationships between EAPs and alcoholism treatment, a circumstance of mutual dependency but imperfect communication. Part III consists of three chapters. The first touches upon many of the issues raised in the foregoing chapters and provides an overview of part of a long-term

Introduction a n d Overview

15

center of EAP-related research at Cornell University. Harrison M. Trice reviews the research base and a complex set of implications of the strategy of constructive confrontation that is central to the core technology of EAPs. He reviews the different theoretical perspectives and empirical data that have been centered on isolating risk factors in the development of employee alcoholism problems. Finally he describes the research in progress, which is following the development of workers in the EAP field, and provides an indepth account of the processes that affect the development of what may become an institutionalized occupation that can be traced through the progression of events that have brought to prominence alcohol problem intervention in the workplace. The chapter by Harold D. Holder places the set of questions regarding workplace alcoholism intervention in a broad community context and shows that these issues cannot be separated from the larger issues of alcohol problems and their impact on organized human life. Finally, the editor draws together the entire volume in an effort to provide a degree of integration and to offer suggestions and implications for the practitioner in the workplace setting. NOTE Support from Grant Nos. R01-AA-07218 and T32-AA-07473 from the National Institute on Alcohol Abuse and Alcoholism is gratefully acknowledged.

REFERENCES Blum, T.C., and Roman, P.M. (1989, November). Employee assistance programs and human resources management. In K. Rowland and G. Ferris (Eds.), Research in personnel and human resources management, 7, 251-312. Brandes, S.D. (1976). American welfare capitalism. Chicago: University of Chicago Press. Denenberg, T. and Denenberg, R. (1983). Alcohol and drugs: Issues in the workplace. Washington, DC: Bureau of National Affairs Press. Fein, R. (1984). Alcohol in America: The price we pay. Minneapolis, MN: Care Institute. Holder, H.D. (1987). Alcoholism treatment and potential health care cost savings. Medical Care, 25, 52-71. Holder, H.D., and Hallan, J.B. (1986). Impact of alcoholism treatment on total health care costs: A six-year study. Advances in Alcohol and Substance Abuse, 6, 1-15. Roman, P.M. (1980). Medicalization and social control in the workplace: Prospects for the 1980's. Journal of Applied Behavioral Science, 16, 407-422. Roman, P.M. (1981). From employee alcoholism to employee assistance: An analysis of the de-emphasis on prevention and on alcoholism problems in work-based programs. Journal of Studies on Alcohol, 42, 244-272. Roman, P.M. (1988). Growth and transformation in workplace alcoholism programming. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 131-158). New York: Plenum Press. Roman, P., and Blum T. (1987). Notes on the new epidemiology of alcoholism in the USA. Journal of Drug Issues, 17, 321-332.

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Sonnenstuhl, W., and Trice, H. (1986). Strategies for employee assistance programs: The crucial balance (Key Issues No. 30). Ithaca, NY: ILR Press. Sonnenstuhl, W., and Trice, H. (1987). The social construction of alcohol problems in a union's peer counseling program. Journal of Drug Issues, 17 (3), 223-254. Trice, H., and Schonbrunn, M. (1981). A history of job-based alcoholism programs, 1900-1955. Journal of Drug Issues, 11, 171-198.

PARTI THE SOCIAL AND ORGANIZATIONAL CONTEXTS OF ALCOHOL PROBLEMS IN THE WORKPLACE

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2 THE IMPACT OF MACROSOCIAL FORCES ON THE DISTRIBUTION OF ALCOHOL PROBLEMS IN THE WORKPLACE DAVID J . PITTMAN

This chapter discusses some of the major macrosocial forces operating in American society that have implications for both the prevention and treatment of alcohol problems in the workplace. Of major relevance are (1) the state of the American economy; (2) the changing age and ethnic distribution of the American population (the population pyramid); (3) the health promotion movement; and (4) the concern for an environmentally sound workplace. Needless to say, these macrosocial forces cannot be discussed in extensive detail, and my observations are not necessarily complete. They are listed to sensitize one to the fact that alcohol problems in the workplace are influenced by social and economic forces, which appear remote to the practitioner who is operating an employee assistance program (EAP) or even to a researcher in the alcohol problems field.

THE CHANGING AMERICAN ECONOMY A 1988 Fortune magazine article lead is "America's wonderous job-creation juggernaut rolls on and on, seemingly immune to trade deficits and stock market crashes, whatever Democratic or Republican Administration tries to take credit for it. The Bureau of Labor Statistics reports the economy has produced 31 million new jobs since 1972. It will add another 21 million by the end of the century" (Richman, 1988). But not all observers of the economic scene share such an optimistic scenario of the state of the American economy. Many are concerned about such problems as (1) the fact that America is one of the largest debtor nations in the world; (2) the seemingly intractable federal budget deficits; (3) the weakness of the American dollar on foreign exchange markets; (4) the inability of the country

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Social and Organizational Contexts

to produce a favorable trade balance (a trade deficit of $160.7 billion in 1987); (5) an uneasiness since the stock market crash of October 19, 1987, that a recession may be forthcoming; (6) a concern that the educational system is not currently preparing either the economically disadvantaged or the advantaged with adequate skills for jobs which are increasingly complex; and (7) alcohol and drug dependency problems among members of the workforce. Thus the soundness of the American economy will provide the context in which worker expectations but also satisfactions occur. Macroresearch studies which measure the incidence of alcohol-related problems in relationship to the employment level of the society, as well as that of specific subgroupings, should continue to be a high research priority. Furthermore, it is necessary to ascertain how worker expectancies about economic advancement and job satisfaction relate to the distribution of alcohol-and drug-abuse problems in the workplace.

CHANGING AGE AND ETHNIC DISTRIBUTION The aging of the American population is one of the major macrosocial forces that will have a significant impact upon American values in general and in the workplace specifically over the next two decades. As represented by the median age (32.1 years in 1987 as compared to 30.0 in 1980 and 27.9 in 1970) ours is an aging population. The best way to describe the age pyramid in America is in terms of a middle-age spread; that is, the largest grouping is that of the baby boomers who are between 25 and 44 years of age. These approximately 80 million people, who include the yuppies (young urban professionals) made famous by the mass media in the 1984 national election campaign, compose over one-third of the population. But they are growing older—each day for the next few years around 10,000 will experience the joys of "life begins at 40." This inevitable graying of the population has major implications for the American workforce in that those who are in the younger age brackets are less numerous. One economic scenario is that labor shortages may become severe if jobs continue to be created at their current pace. What will be the impact of labor shortages in many key sectors of the economy for alcohol- and drug-abuse problems? Will this growth in job opportunities allow individuals with alcohol problems to move easily to other employment situations? The baby boomers as a group have postponed marrying; they do not marry in their late teens and early twenties as did their parents. Later ages at first marriage for both males (average 26) and females (average 24) have resulted in lower birth rates. Therefore, there will be no significant increase in the proportion of the population which is under 20 years of age in the foreseeable future. At the other end of the age pyramid, given advances in medical science and concern for good health, more people are living to an older age. In fact, two of the fastest growing age brackets are 85 years of age and over and 75 to 84, which increased 22.2 percent and 7.7 percent respectively in 1987. Thus America is an aging

Impact of Macrosocial Forces

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society—a fact that has profound implications not only for the economy but also for the general values of the society. Concomitant with an aging population is the changing ethnic composition of the American population, given the recent high rates of immigration from Latin and Central American and Asian countries. Since 1960, the cultural diversity in the society has increased. The customs of a larger number of Hispanic and Asian Americans added to black Americans means that a greater variety of cultural patterns is encountered than was the case in the early 1960s. Furthermore, these groups (blacks, Hispanics, and Asians) are composed of younger populations on the whole than the remaining Americans. For example, census data indicate that in 1987 the median age for blacks was 27.2 years compared to 33.0 years for whites. These changes in the age and ethnic distributions in the American population have notable implications for the composition of the workforce and for attitudes toward alcoholic beverages. The higher median age of the population means that fewer younger individuals will be entering the workforce yearly; already many minimum wage jobs performed by teenagers and unskilled individuals are difficult to fill in many parts of the country. If the economy continues to generate jobs as it has for the last two decades, then certain industries may experience a serious shortage of workers. Therefore one can foresee a scenario in which EAPs will be not only expanded, but expected to perform at a higher rate of effectiveness. Moreover, the ethnic composition of the labor force is expected to change notably by the year 2000. The Bureau of Labor Statistics estimates that the Hispanic and Asian workers will increase by almost 75 percent and blacks by over 25 percent by the beginning of the twenty-first century, by which time the workforce will be 74 percent white, 12 percent black, 10 percent Hispanic, and 4 percent Asian (Richman, 1988). Thus alcohol studies researchers will need to document more thoroughly the attitudes toward and the patterns of drinking and concomitant behaviors of Hispanics, blacks, and Asians. Also crucial, given the fact that women will continue to enter the labor force in increasing numbers in the next decade, is the need for research on the interaction of gender with the workplace. The necessity of employers to make additional provisions in their company policies for maternity leave, child-care facilities, and so on, will be based on their need for attracting women to their ranks, given the scarcity of workers. Thus, EAPs will have to evaluate systematically whether their programs are sensitive to the needs of a changing workforce in terms of gender and ethnic status. As the population ages, American society will be less youth oriented. Younger groups, especially those under 25, will be less influential in shaping societal attitudes including those toward alcoholic beverages. Youth is a time of trying out various identities, experimenting with many forms of behavior, usually casting them aside as being inappropriate, and settling down by the middle twenties to a career and a family. Frequently negative forms of behavior burn out as youthful energy is dissipated. In American society in some male youth groups,

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Social and Organizational Contexts

heavy consumption of alcoholic beverages, frequently leading to drunkenness, is perceived as being a sign of masculinity and the badge of adulthood. More in-depth ethnographic studies of the male macho-oriented youth groups are a major research priority in my opinion. The impact of the 1984 national legislation, of increasing the legal purchase age for alcoholic beverages to 21 years of age under the threat of the loss of federal highway traffic safety funds, upon the behavior of these macho-oriented groups is a question for research to answer. Automobile crashes involving alcohol are disproportionately concentrated in the male age brackets of from 16 to 25 years of age. Thus, given the aging of the population, the trend lines of drunken driving arrest rates should be downward, because individuals tend to become more responsible as well as more experienced drivers as they become older. A myriad number of behavioral science studies indicate that individuals as they age, unless they are chronic alcoholics, drink less. Per capita consumption of absolute alcohol by the drinking age population of 14 years of age or older began to stabilize in the United States in the early 1980s and is now on the decline. Moreover, sales of alcoholic beverages declined in 1987 from their 1986 levels: beer by 1.2 percent and wine and distilled spirits by 2.5 percent (Sharkley, 1988). This decline cannot be attributed to an increase in abstainers, because they continue to remain relatively constant—slightly over one-third of the drinking age population. Thus the population on the whole drinks less than it did five years ago. The alcoholic beverage industry should not expect any increase in overall per capita consumption in the next decade; moreover, the decline in per capita consumption should continue at its modest rate given the aging population. In summary, the aging labor force should be characterized by a more mature worker on the whole, one who is more concerned with stability of employment than his youthful counterpart. Just envision the Bureau of Labor Statistics forecast for the year 2000: the median age of the worker will be almost 40 (39.6) and the fastest growing segment of the labor force will be 55 years or older (Richman, 1988). THE HEALTH PROMOTION MOVEMENT Another macrosocial trend is the emphasis placed upon physical fitness by vast segments of the American population. The health promotion movement, reinforced by constant coverage by the mass media, emphasizes that the key to longevity is found in a moderate lifestyle. The moderate lifestyle involves either stopping or never beginning smoking, weight reduction to appropriate limits, a low cholesterol diet, and exercise that invigorates the cardiovascular system. Despite the rash of studies which show a negative association between moderate drinking of alcoholic beverages and heart attack, this relationship should be researched more thoroughly (Rohan, 1984). Some health promotion movement advocates stress the nonuse of drugs; since these agents contaminate the "holy temple" of the body, one should not use nicotine, caffeine, alcohol, or illicit

Impact of Macrosocial Forces

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drugs, such as marijuana or cocaine. Thus, today there is a lifestyle, adopted by some Americans, that is an alcohol-free one; admittedly an even more numerous group advocates moderation in drinking. Both groups have minimal tolerance for either public or private displays of drunkenness. This negative sanctioning of inappropriate drinking and behavior while drinking is a positive change in American values. These changing attitudes toward drunkenness should be a major focus for future research. Of relevance to EAPs is the question of how peer pressure toward inappropriate behaviors while drinking by fellow workers can be harnessed to intervene earlier in the workplace context. ENVIRONMENTAL MOVEMENTS Among the numerous social movements which developed in the turbulent 1960s were ones concerned with the condition of the environment; its major foci were cleaner water and air as well as safe and sanitary workplaces. The Environmental Protection Agency was created by legislation to be the lead agency not only to develop environmental standards but also to enforce compliance with these new norms for air and water purity. In the workplace the emphasis has been on the creation of an environment that does not pose undue hazards to the worker. Of importance here is one major environmental social movement—a smokefree workplace—as well as its implications for alcohol research at the worksite. A quarter of a century ago, the Report of the Advisory Committee to the Surgeon General of the Public Health Service, Smoking and Health (Department of Health, Education and Welfare, 1964) with its thorough documentation of the risks to one's health associated with smoking was released. In 1975, within a decade, Minnesota passed the first Comprehensive Clean Indoor Air Act which regulated smoking in public places. Today at least forty-two states restrict smoking in public places including the working environment. Thus, given not only the health risk to workers from their smoking but also the dangers of inhaling secondary smoke, employers in increasing numbers are restricting smoking to specific areas or banning it entirely in the workplace. This trend should accelerate when other employers join Turner Broadcasting Company in refusing to employ individuals who smoke. Thus one can predict that the next battle will be fought over whether it is sufficient for employees to be "smoke free" on the job or whether employers will require the status of being a "smoke-free" individual as a condition of employment. This latter issue, of course, raises civil liberties issues which are beyond the scope of this chapter. A smoke-free workplace has implications for those in alcohol research and policy. The workplace is one in which illicit drugs are prohibited, and the use of alcoholic beverages is confined to specific contexts and occasions. But there is a fundamental distinction between the requirement that workers be dry on the job and the maintenance of an alcohol-free workplace. The underpinnings for a social movement which has its focus on an alcohol-free environment are already

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in place. The Alcohol Policy Bill of Rights of the National Association for Public Health Policy (1987) states under its heading of "The Right to Safe Workplaces" that "employees have a right to workplaces free of pressures to consume alcohol." Given the concern with the dangers of consumption of alcohol in the workplace, will such events as the following one become a relic of the past? [Thefirm]has fired six associate lawyers and asked two partners to leave in wake of the firm's forced withdrawal from the . . . bankruptcy case. . . . To boost the morale of its remaining employees thefirmheld a cocktail party at its Clayton offices Tuesday evening. (MacLochian and Koman, 1988) An alcohol-free workplace movement would sever the intimate connection between consumption of alcoholic beverages and the conducting of business, particularly at the managerial level. But such a movement would of course have as its goal abolishing the Christmas office party, the serving of alcoholic drinks in company dining rooms, the employer's gifts of alcoholic beverages, and so on. But how much resistance would such measures engender? Moreover, issues of employer financial liability for those who serve alcoholic beverages to their employees will become more vexing in the next decade. A social movement to establish an alcohol-free workplace is a logical extension of a smoke-free one for the society. But more difficult to accomplish would be social movements that would require workers to be alcohol free while not on the job. Such policies were adopted by some employers in previous American temperance movements, especially during the Prohibition era earlier in this century. The fact that texts on alcohol and alcoholism have been classifying alcohol as a drug (e.g., Royce, 1981) for decades means that it is only a short step for those most active in the current war on drugs to include increased restrictions on the availability of alcoholic beverages in their mission to create a drug-free America. There is strong evidence, despite the fact that ethyl alcohol is not included in the drug schedules of the federal Controlled Substance Act of 1970, that the Office of Substance Abuse Prevention wishes to emphasize that alcohol is a drug. For example, in a recent public information release, the following statement is included: "To emphasize that alcohol is a drug, it is recommended that the phrase 'alcohol and other drugs' be used instead of 'substance abuse.' This new phrase emphasizes the fact that alcohol should be recognized as a drug" (National Institute on Alcohol Abuse and Alcoholism, 1988). CONCLUSIONS Sound scientific research studies, instead of claims-making activity by moral, bureaucratic, and private enterprise entrepreneurs, are needed to provide information on which social policy on alcohol problems in the workplace can be constructed. For example, precise empirical studies are needed to document the claim that alcohol abuse in 1983 cost society $ 117 billion, of which approximately

Impact of Macrosocial Forces

25

$71 billion (61 percent) resulted from lost employment and reduced productivity (National Institute on Alcohol Abuse and Alcoholism, 1987). A recent critical analysis of current methods and estimates to obtain these economic costs demonstrates the need for improvement in developing measures of costs (Heien and Pittman, 1989). Research studies which document more thoroughly the association between the various states of health and drinking status are essential. The future course of the debate on alcohol policy in the workplace will be strongly shaped by research findings such as these.

REFERENCES Department of Health, Education and Welfare. (1964). Smoking and Health, Report of the Advisory Committee to the Surgeon General of the Public Health Service. (Public Health Service Publication No. 1103). Washington, DC. Heien, D.M. and Pittman, D.J. (1989). The economic costs of alcohol abuse: An assessment of current methods and estimates. Journal of Studies on Alcohol, 51. MacLochian, Claudia, and Koman, Karen L. (1988, March 6). Apex law firm fires lawyers to trim costs. St. Louis Dispatch, p. 1C. National Association for Public Health Policy. (1987). Alcohol policy bill of rights. Council on Alcohol Policy. National Institute on Alcohol Abuse and Alcoholism. (1987). Alcohol and health. Sixth Special Report to the U.S. Congress. Rockville, MD: U.S. Department of Health and Human Services, p. 21. National Institute on Alcohol Abuse and Alcoholism. (1988). The fact is . . . , Rockville, MD: National Clearinghouse for Alcohol and Drug Information, p. 3. Richman, Louis S. (1988, April 11). Tomorrow's jobs: Plentiful, b u t . . . , Fortune, p. 42. Rohan, T.E. (1984). Alcohol and ischemic heart disease: A review. Australian and New Zealand Journal of Medicine, 14, 75-80. Royce, J. (1981). Alcohol problems and alcoholism. New York: Free Press. Sharkley, B. (1988). The new sobriety. Adweek's Marketing Week, XXIX, p. 47.

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3 EMPLOYED ADULTS AT RISK FOR DIMINISHED SELF-CONTROL OVER ALCOHOL USE: THE ALIENATED, THE BURNED OUT, AND THE UNCHALLENGED DOUGLAS A. PARKER AND GAIL C. FARMER

THE ALIENATION PARADIGM For more than a century, social scientists and others have been concerned with alienation in the workplace and its effects on behavior outside of the workplace. For Karl Marx, alienated labor was activity conceived and directed not by the worker but by others in which the worker "does not affirm himself but denies himself, does not feel content but unhappy, does not develop freely his physical and mental energy but mortifies his body and ruins his mind" (Marx, 1964, 110). As we interpret Marx's formulation, alienation has both social-structural and psychological domains. It comprises both what people do when they are engaged in alienated labor and how they feel about what they do. And the effects of alienation can extend beyond the workplace as Friedrich Engels has suggested: "On Saturday evenings, especially when wages are paid and work stops somewhat earlier than usual, when the whole working-class pours from its own poor quarters into the main thoroughfares, intemperance may be seen in all its brutality" (quoted in Wilensky, 1960, 544). During the past 25 years, M.L. Kohn and his associates (Kohn and Schooler, 1983; Kohn, 1987) have provided strong evidence that job conditions that facilitate or restrict the exercise of self-direction in work—particularly the substantive complexity of work with data, people, and things—affect workers' values, orientations, and intellectual functioning through a process of learning generalization. Kohn and his associates have not made a concerted and sustained effort to situate their work in classical social theory. Kohn (1976) has, however, implied that the complexity of work indexes the social-structural domain of alienation that involves loss of control over the work process and that two types of orientation, powerlessness and self-estrangement, index the psychological

28

Social and Organizational Contexts

domain of alienation which involves disillusionment with the world and with oneself. In the introduction to an empirical analysis which showed that less complex work was associated with greater powerlessness and self-estrangement, Kohn noted that, "only rarely are the social-structural and psychological aspects of alienation juxtaposed" (Kohn, 1976, 111). It can also be noted that even more rarely are these aspects of alienation considered together in relation to a behavior such as the use of alcohol. In research which considered the impact of both the social-structural and psychological domains of alienation on the drinking behavior of employed men, M. Seeman and his associates (Seeman and Anderson, 1983; Seeman, Seeman, and Budros, 1988) did not find effects of less complex work and of less job latitude an index of decision-making and skill involvement in work, but they did find effects of powerlessness. They found that a generalized sense of powerlessness (low personal mastery) was associated with heavier drinking and drinking problems. Seeman and his associates also found that powerlessness itself was not associated with substantive complexity and other conditions of work, most of which were subjective reactions to the job (satisfaction with the intrinsic qualities of work, overall job satisfaction, and occupational striving or commitment). Perhaps the key finding of their research was the discovery that the men who have more engaging and demanding work and a greater sense of powerlessness are the men who have the highest alcohol problem scores. On the basis of these findings, Seeman and his associates questioned the thesis that there is a generalization of the lessons of the job to other spheres of life experience. The research by Seeman and his associates should command our attention. Those of us who conduct studies of employment experience need to clarify what it is about substantive complexity and the other alienations that could influence drinking behavior. Further, we need to understand why men who are not alienated in work but are psychologically alienated are at risk for alcohol problems. Seeman and his associates do not provide an explanation for this interaction effect in their demographically homogeneous sample of employed men from one Los Angeles community, but they do suggest that, "it is a reminder that unalienated work has its risks and frustrations, too" (Seeman and Anderson, 1983, 74; also cited in Seeman, Seeman, and Budros, 1988, 193). Heavier drinking may be a response to a lack of "fit" between jobs and the needs and capacities of some men and women. R. Straus (1976) has argued that the job experiences in modern industrial societies often fall into two categories: the jobs have greater responsibilities and require more time involvement than most men and women can usually withstand, or the jobs are undemanding and provide insufficient challenge. Straus has not attempted to show that alcohol is consumed as a response to these experiences, but we intend to do so. Using Kohn and his associates' measure of substantive complexity and not the one from Seeman and Anderson's analysis (1983), we will explore the relationships between substantive complexity, the psychological alienations, and self-control over alcohol use among a demographically heterogeneous sample of employed

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29

adults. Our objective is to determine whether some support can be found for the generalization thesis and for the "fit" thesis that jobs which are incongruent with the needs and capacities of some men and women are conducive to the use and abuse of alcohol. The data on which our analysis is based come from a household survey of 1,367 men and women, representative of employed men and women in metropolitan Detroit, who were interviewed for us by the Policy Research Corporation during the summer and fall of 1978. Respondents were men and women 18 years of age and older who were employed thirty or more hours per week. Women were oversampled in order to permit a detailed examination of their occupational experiences, psychological functioning, and drinking behavior. Specific information on the sample and research design are given in Parker and Brody (1982) and Parker et al. (1983). PROBLEMATIC AND IMPAIRED CONTROL In Kohn's only involvement with studies on job conditions and drinking behavior, he suggested that one of the first items on the research agenda was to specify what aspects of alcohol use and abuse might be affected by conditions of work (Kohn, 1978). This is an obvious task, but to perform it we need to appropriate the central concept in the modern theory of alcoholism—the idea that there is a diminution of one's self-control over drinking behavior as the "disease" of alcoholism progresses. One of the earliest formulations of the concept of diminishing self-control was advanced by E.M. Jellinek (1960, 1962) who argued that scientists and health care providers should focus their attention and efforts on two kinds of alcoholics: "symptomatic drinkers," or "alpha alcoholics" who drink heavily to relieve bodily or emotional distress, and "alcohol addicts," or "gamma alcoholics" who are physically dependent on alcohol and experience loss of control over their drinking. Jellinek contended that symptomatic drinkers or alpha alcoholics are in a prealcoholic stage of addiction. Control over alcohol use has not been lost, but symptomatic drinkers find it necessary to rely upon the effect of alcohol to cope with the major stresses of everyday life (Jellinek, 1962). Jellinek suggested that in many cases symptomatic drinkers or alpha alcoholics may become alcohol addicts or gamma alcoholics, but he also pointed out that symptomatic drinking "may be seen in a drinking career of 30 or 40 years without any signs of progression" (1960, 37). According to Jellinek, alcohol addicts or gamma alcoholics are at an advanced stage in the development of the disease because control over alcohol use has been lost. Once addicts begin to drink, they feel a compulsion to drink until they are too intoxicated or sick to ingest more alcohol. The addicts also experience physical dependence on alcohol in the form of withdrawal symptoms such as shakes and tremors and problems with health, productivity, and interpersonal relationships (Jellinek, 1962).

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Self-control over alcohol use by symptomatic drinkers should be viewed as problematic. We simply do not know whether reliance on the psychoactive effects of alcohol should be regarded as anything more than alcohol use. As D. Cahalan and R. Room put it somewhat more argumentatively, to treat mood-changing reasons for drinking as an alcohol problem "is to subscribe to some degree to a Calvinist asceticism, setting up an ideal of 'systematic self-control' which allows no time off from moral responsibilities" (1974, 20). Self-control over alcohol use by alcohol addicts probably should be seen as "variably and intermittently impaired rather than 'lost' " (Edwards and Gross, 1976, 1060). Although we can continue to speak of loss of control when we are referring to the compulsion addicts feel after they begin to drink, it is not necessary to view addicts' control over alcohol in categorical terms, particularly if that control is seen as being reflected in other aspects of addicts' behavior and functioning such as in blackouts and memory lapses where control may be only impaired. The two types of control, one problematic and the other impaired, are the focus of our empirical examination. Guided by the concept of diminishing selfcontrol, we were able to construct measures for what we call "problematic control" and "impaired control." For us, control over alcohol use becomes problematic when men or women engage in heavier drinking as a means of changing moods. Our index of problematic control is the maximum quantity of alcohol consumed during the past month by those who reported that drinking cheered them up, helped them forget their worries, helped them cope with feeling tense or nervous, or made them feel better. Problematic control is expressed in ounces of absolute alcohol: the mean for men was 1.66 ± 2.45 (sd) and for women was 1.07 ± 1.95 (sd). Control over alcohol use becomes impaired when men or women who drink heavily experience withdrawal symptoms, loss of control, blackouts, and other symptoms of pathological alcohol use, belligerence, job disruption, and social reactions (Parker et al., 1983). Our index of impaired control is the sum of these experiences during the past year for those who consumed five or more drinks on at least one occasion during this period of time (a heavy drinking criterion used by Hilton, 1987). The impaired control mean for men was 1.09 ± 2.38 (sd) and for women was 0.43 ± 1.56 (sd).

STRUCTURAL AND PSYCHOLOGICAL ALIENATION Seeman and Anderson (1983) note that the alienation paradigm has more than one domain, but they seem reluctant to convey an appreciation of the socialstructural domain (they do not cite or discuss Kohn's 1976 analysis of alienation) or to provide an explanation for the unexpected combination of the domains that they found in their data. In order to assess the effects of these domains, we use Kohn and his associates' measure of substantive complexity to index the social-

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31

structural domain of alienated labor and to develop our own measures of powerlessness and self-estrangement as indices for the psychological domain. Substantive complexity is "the degree to which performance of the work requires thought and independent judgment" (Kohn and Schooler, 1982, 1261). We view less substantively complex work as alienated labor. Complexity of work with data ranges from conceiving approaches to problems and developing knowledge to transcribing, entering, or posting data. Complexity of work with people can range from mentoring or negotiating with people to receiving orders or serving people. Complexity of work with things can range from setting up machines so that they will perform their functions to repetitive actions which are paced by a machine. Our complexity measure is a composite of seven ratings: our appraisals of the complexity of each man or woman's work with data, with people, and with things; our appraisal of the overall complexity of each man or woman's work; and each man or woman's estimates of the amount of time he or she spends in each type of activity. A factor analysis of these ratings yields a single index of substantive complexity. The complexity measure does not appear to reflect systematic biases in respondents' reports about their jobs. We can compare our measure of complexity which is based on each respondent's description of his or her job with the assessments given in the fourth edition of the Dictionary of Occupational Titles (U.S. Department of Labor, 1977) for every occupation in the American economy. The Dictionary's ratings of the complexity of work with data, with people, and with things are averages for specific occupations, but because they are based on observations by trained analysts, we can use them as a source of external validation. Kohn and Schooler (1973) found that the multiple correlation between substantive complexity and the independently coded ratings of the third edition of the Dictionary (U.S. Department of Labor, 1965) to be 0.78 among the men in their study. We found the multiple correlation between substantive complexity and the independently coded ratings of the fourth edition of the Dictionary to be 0.79 among the men and 0.70 among the women in our study. These correlations are of sufficient magnitude to assure us that our appraisals of substantive complexity accurately reflect what men and women do in the performance of their work. Seeman and Anderson used the rating of substantive complexity developed by Miller, Treiman, and Cain (1980) which is more a measure of what workers must bring to the job than of what they actually do on the job. From a factor analysis of occupational characteristics in the fourth edition of the Dictionary of Occupational Titles in which the characteristics had to load at least 0.5 on a primary factor and less than 0.3 on remaining factors, a complexity factor was defined as constituting the complexity of work with data, general educational preparation, specific vocational preparation, and items dealing with aptitudes, interests, and temperament demanded of workers in certain jobs. Seeman and Anderson incorrectly state that the substantive complexity factor "is defined by high loadings on the complexity of the worker's functions in dealing with data,

32

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people and things" (1983, 65) because complexity of work with people and things did not meet the criterion set by Miller et al., and were excluded from the substantive complexity factor scale. Given their measure, Seeman and Anderson's findings might be more accurately interpreted as indicating that what workers bring to the job in terms of training, aptitudes, interests, and temperament are not particularly pertinent for understanding their use of alcohol. The two types of psychological alienation in our study, powerlessness and self-estrangement, refer to employed persons' lack of faith in the external world or themselves. Powerlessness refers to "the expectancy or probability held by the individual that his own behavior cannot determine the outcomes, or reinforcements, he seeks" (Seeman, 1959, 784). As Kohn points out, the concept implies a continuum of external and internal control, from the individual's being subject to external forces to having some degree of control over his or her own fate (Kohn, 1976). Self-estrangement "refers essentially to the inability of the individual to find self-rewarding—or in Dewey's phrase, self-consummatory— activities that engage him" (Seeman, 1959, 790). As Kohn notes, the concept implies a sense of low self-esteem, although it also implies a sense of being detached from oneself, of being bored and disinterested in what life has to offer, rather than of being engaged in it (Kohn, 1976). Our measures were extracted from a factor analysis of eight items which had similar loadings on each factor in both men and women. A two-factor solution was employed in order to minimize problems of collinearity. Powerlessness is measured by responses to four questions concerning whether employed persons felt there was no way they could solve their problems, felt they were being pushed around in life, felt they had little control over things that happened to them, and felt hopeless in dealing with the problems of life. Self-estrangement is measured by responses to four questions concerning whether employed persons felt useless at times, lacked enthusiasm for doing anything, thought that they were no good at all, and felt bored or had little interest in things. In addition to substantive complexity, powerlessness, and self-estrangement, we have indexed other job conditions and background factors which may be related to alcohol use. These variables are described in detail elsewhere (Parker and Farmer, 1988). Economic sector classifies firms or organizations in which men and women are employed in terms of whether the organizations are part of the state or private sectors of the economy. Industrial sector classifies firms or organizations according to whether they are in the core or periphery sectors of the economy using the coding by Tolbert, Horan, and Beck (1980). Organizational size characterizes firms or organizations in terms of the number of their employees. Class relations include legal ownership of a business, managerial control over what is produced or sold, managerial control over how something is produced, and supervisory control over the labor of others; these are indexed by a Guttman scale (Parker and Maattanen, 1987). Contradictory relations are experienced by the middle stratum of managers and supervisors and are measured by how often the middle stratum is held accountable for things beyond their

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control by those above (legal owners) and by those below (nonsupervisory employees). Routinization ranges from work being paced by a machine to doing many different kinds of things. Job competition is the amount of competition by others for the men or women's jobs, for advancement, for sales, or for anything else of importance. Time pressure is how often the men or women had to work under pressure of time. Dirtiness of work is how dirty the men and women get during their jobs. Heaviness of work is the amount of physical labor that the men or women do in their work. Hours of work is the number of hours per week that the men or women are employed. Job stress is the product of the frequency of feeling tense, worried, or upset about the job and the intensity of these feelings. Background variables included in the analysis were age, education, family income, economic strain, race, marital status, father's socioeconomic status, and father's drinking. Economic strain is how much difficulty the men and women had in meeting monthly payments on their personal or family bills. The father's socioeconomic status is indexed by the Duncan Socio-Economic Index (1961). The father's drinking classifies the men and women's fathers as nondrinkers, light drinkers, moderate drinkers, heavy drinkers, or very heavy drinkers based on the respondents' descriptions. THE ALIENATIONS AND ALCOHOL USE Table 3-1 provides the correlations of the alienation variables with the other variables in our analysis. In Detroit, the men and women who perform work that is substantively complex are more likely to be in the state sector of the economy, to be higher in the class structure, to experience demands for accountability if they are supervisors and managers in contradictory locations, to have less routinized work, to have greater job competition and time pressures, and to have less involvement with work that is dirty or heavy. The men who do substantively complex work are more likely to be in the peripheral sector of the economy, and the women who do complex work with data, people, and things are more likely to be in smaller organizations. Both the men and women who do substantively complex work are more likely to be white and married, to have higher educational attainment, to have greater family income, and to have had fathers with higher socioeconomic status. Seeman and Anderson did not find powerlessness correlated with any of their measures of job experience, but they did acknowledge that they might "have missed those specific dimensions of work" that might produce a sense of powerlessness (1983, 75). The findings from Kohn's study (1976) did provide such evidence, and so does the correlational data from this study. As Table 3-1 indicates, men and women who have a greater sense of powerlessness are more likely to do less substantively complex work, to be found in the core sector of the economy, and to be involved in work that is dirty. The men who experience powerlessness are more likely to be lower in the class structure, and the women who experience powerlessness tend to have more routinized work. Both the men

Social and Organizational Contexts

34

Table 3-1 Correlations of Alienation Variables with Other Variables among Employed Men (N = 643) and Women (N = 724) Subetantiv* Complexity Hen Women

Powerlessness Hen Women

SelfEstrangement Men Women

ALIENATION Substantive Complexity Powerlessness Self-estrangement

I.OO* -.07* .00

I.OO* -.15* -.13*

-.07* 1.00* .20*

-.13* 1.00* .21*

.OO .20* l.OO*

-.13* .21* l.OO*

.12* -.09* -.02 .44* .38* -.47* .28* .21* -.44* -.56* .21* .12* .13* .34* .35* -.06 .12* -.07-.18* .19* .02

.17* .01 -.09* .36* .26* -.41* .11* .10* -.26* -.37* .06 .03 -.00 .33* .18* -.14* .18* -.09* -.01 .31* .02

-.04 .15* .06 -.17* -.05 .06 -.01 -.07* .12* -.01 -.04 .10* .01 -.08* -.06 .06 -.04 .11* .07* .04 .07*

.02 .07* .03 -.06 -.OO .12* -.09* .01 .07* .04 -.04 .10* -.03 -.08* -.09* .14* -.08* .04 .OO -.04 .08*

.OS .08* .04 -.10* .03 -.07* .09* .09* .OS .OO -.04 .23* -.19* .04 -.04 .10* .08* .10* .06 -.03 .16*

-.01 .01 .01 -.11* .02 .04 .11.04 .08* .01 -.09.30* -.22* -.08* -.09* .16* -.02 .02 .17* .03 .10*

.01 -.11*

-.07* -.11*

-.01 -.07*

.07* .09*

.23* .26*

.13* .18*

OTHER JOB CONDITIONS & BACKGROUND FACTORS Economic Sector Industrial Sector Organizational Size Class Relations Contradictory Relations Routinization Job Competition Time Pressure Dirtiness of Work Heaviness of Work Hours of Work Job Stress Age Education Family Income Economic Strain Race Previously Married Never Married Father's S.E.S. Father's Drinking ALCOHOL

USE

Problematic Control Impaired Control

»p < .05.

and women who have a greater sense of powerlessness are more likely to be less educated and to have had heavier drinking fathers. Self-estrangement is also correlated with job conditions and background factors. Men and women who have a greater sense of self-estrangement are more likely to be in lower positions in the class structure and to have greater job competition. The men who experience self-estrangement are more likely to work in the core sector of the economy and have greater time pressures. The women who experience self-estrangement are more likely to do less substantively complex work and to be involved with work that is dirty. Both the men and women

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who have a greater sense of self-estrangement are more likely to be younger, to experience greater economic strain, and to have had heavier drinking fathers. Table 3-1 also shows that substantive complexity and the psychological alienations are associated with diminished self-control over alcohol use. Less complex work is associated with impaired control among the men and with both problematic and impaired control among the women. Powerlessness is inversely related to impaired control among the men but directly related to both forms of diminished self-control over alcohol use among the women. Greater self-estrangement is associated with greater problematic and impaired control in both men and women. Not shown in the table is that problematic and impaired control are associated with employment in smaller organizations (among the men only), greater job competition, younger age, less education (among the women only), and heavier father's drinking. Following the procedures used by Seeman and his associates, we examined the possible interactions among the alienations in order to determine whether there were particular combinations that placed men and women at higher risk for problematic and impaired control over alcohol use. We conducted several analyses of covariance using the regression approach wherein all effects, including main effects, covariate effects, and any interaction effects, were assessed simultaneously as in a regression analysis. Among the men, in addition to the main effects of substantive complexity (on impaired control only) and of selfestrangement, and the covariate effects of job competition, organizational size, age, and father's drinking, there were three-way interaction effects of complexity, powerlessness, and self-estrangement on problematic control (p. < .05) and on impaired control (p. < .05). Among the women, in addition to the main effects of substantive complexity and of self-estrangement (on impaired control only), and the covariate effects of age and father's drinking, there were two-way interaction effects of complexity and self-estrangement on problematic control (p. < .10) and on impaired control (p. < .05). These interaction effects can be seen in Table 3-2, which displays the adjusted means for problematic and impaired control for both men and women (adjusted for the effects of job competition, organizational size, age, education, and father's drinking). Three groups of the men and two groups of the women appear to be at risk for diminished self-control over alcohol use. One group of men has more complex work and a greater sense of powerlessness and self-estrangement (see column 4, rows 1 and 3) and may be not unlike a group of men from a Los Angeles community studied by Seeman and Anderson (1983). They found that the men who had the highest total drinking problems scores were the men who were involved in intrinsically satisfying work, received high network support, and had a greater sense of powerlessness. The Detroit men who have more complex work and a greater sense of powerlessness and self-estrangement may be experiencing what is called burnout (Maslach, 1982). The similar combination of alienations among the Los Angeles men in Seeman and Anderson's analysis may also indicate a condition of extreme

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Table 3-2 Adjusted Mean Scores for Problematic and Impaired Control by Substantive Complexity, Powerlessness, and Self-Estrangement*

Alcohol Variable and Substantive Complexity

Low Powerlessness

High Powerlessness

Self-Estrangement Low High

Self-Estrangement Low High

(1)

(2)

(3)

(4)

Hen Problematic Control (1) High Complexity <2> Low Complexity

1.33 0.84

1.82 2.33

1.19 1.53

1.99 1.94

Impaired Control <3> High Complexity <4> Low Complexity

0.81 0.59

0.79 2.64

0.37 0.91

1.31 1.24

Women Problematic Control <5> High Complexity <6> Low Complexity

0.81 0.98

0.78 1.38

1.24 1.13

0.94 1.32

Impaired Control <7> High Complexity (8) Low Complexity

0.31 0.20

0.18 0.88

0.33 0.32

0.28 0.90

•Job competition, organizational size, age, education and father's drinking arm controlled. Adjusted scores are based on more than forty cases in each cell.

stress or burnout. Some job experiences may have too much challenge and responsibility, too much complexity of work with data, people, and things and may exhaust the capacities of some of the men who have these experiences. When this occurs, if the men's sense of powerlessness and self-estrangement, perhaps already heightened by having fathers who drank heavily and their own previous alcohol use, is elevated still further by job conditions that are too demanding, the men may become depersonalized or burned out, and their control over all aspects of their personal lives, including their use of alcohol (and other drugs not examined in this analysis), may become seriously impaired. Compared to the other men in the sample, the 70 men referred to as the burned out have significantly greater job competition and time pressure and felt the job stress that we have found to be related to alcohol abuse (Parker and Farmer, 1988). These men also are more likely to be managers and supervisors who have to account for things beyond their control, and to have less routinization, dirtiness, and heaviness of work. They also are more likely to have never married and to have more education and family income. This is the occupational and

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sociodemographic profile that we would expect of persons who are experiencing burnout (see Cherniss, 1980). A second group of men and a group of women at risk for problematic and impaired control have less complex work and greater self-estrangement but also have a sense of mastery or low powerlessness (see column 2, rows 2, 4, 6, and 8). Our interpretation of this combination of the alienations is that this combination constitutes the condition of being unchallenged. The men and women have a self-assessed capability for controlling the events in their lives, but their jobs are incongruent with this evaluative orientation. Being unchallenged in their jobs and lacking control over the conditions of their labor, these men and women may have an affective response of self-estrangement, of being bored and disinterested in things. Not having much demanded of them on the job and not demanding much of themselves off the job, these men and women may become involved in undemanding activities, such as the heavier use of alcohol, and may experience diminished self-control over that involvement. Compared to the other men in the sample, the 62 men referred to as the unchallenged have significantly more routinization, dirtiness, and heaviness of work and are more likely to be in lower positions in the structure of class relations, to experience less job competition, and to have fewer hours of work. They are also younger, have less education and family income, and are more likely to have had fathers with lower socioeconomic status. Compared to the other women in the sample, the 63 women also called the unchallenged have significantly more dirtiness and heaviness of work and are more likely to be in the private sector of the economy and in lower positions in the structure of class relations. They have less education, and they are more likely to have never married and to have had fathers with lower socioeconomic status. A third group of men and a second group of women, who are at risk for problematic and impaired control, have low complexity, high powerlessness, and high self-estrangement (column 4, rows 2, 4, 6, and 8) and may be not unlike an unidentified group in Seeman and Anderson's study. Noting that the group of Los Angeles men who we have suggested are experiencing burnout have the highest scores for total drinking problems, Seeman and Anderson comment that, '4[t]here is certainly no evidence here of an accretion of negatives whereby the three alienations additively take their toll" (1983, 73). But Seeman and Anderson fail to point out that the second highest scores for each of their drinking variables are among the group for which there is an accretion of negatives: less intrinsically satisfying work, less network support, and high powerlessness (1983, 73, Table 6, column 1, rows 2, 4, and 6). And in their recent analysis, Seeman and his associates also fail to point out that the second highest scores for frequency of use, quantity consumed, and drinking problems are among the group for which there is an accretion of negatives: low job latitude, low network support, and high powerlessness (Seeman, Seeman, and Budros, 1988, 191, Table 2, column 1, rows 2, 4, and 6). Compared to all of the other men in the Detroit sample, the 63 men referred

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to as the alienated have significantly more dirtiness and heaviness of work, are more likely to be in the private sector of the economy and in lower positions in the structure of class relations, and have less job competition, less time pressure, and fewer hours of work. They are also younger, have less education and family income, and experience more economic strain. They are also more likely to be white and previously married. Compared to the other women in the sample, the 85 women referred to as the alienated have significantly more routinization, dirtiness, and heaviness of work, and they are more likely to be in lower positions in the class structure and to have fewer hours of work. They are also younger, have less education and family income, experience more economic strain, and are more likely to have never married and to have had fathers with lower socioeconomic status. GENERALIZATION AND LACK OF FIT Seeman and his associates argue that there is little carryover from occupational experience to nonoccupational alienation and to personal behavior such as alcohol use. For the most part, though, Seeman and his associates use subjective reactions to the job rather than the job conditions which give rise to such reactions as the basis for their argument. Thus, Seeman and Anderson use intrinsic satisfaction in work rather than substantive complexity in their covariance models of drinking and drinking problems. But as Kohn points out, 'This approach ignores the possibility that there can be a gap between the conditions to which a person is exposed and his awareness of those conditions, that the existence or nonexistence of such a gap is itself problematic and may be structurally determined, and that conditions felt by the workers to be benign can have deleterious consequences" (1976, 114). Using more measures of job conditions than were included in Seeman and his associates' research, we find that many of these conditions are correlated with a sense of powerlessness and self-estrangement as did Kohn (1976). Indeed, only by ignoring Kohn's causal analysis of the effects of substantive complexity on powerlessness (Kohn, 1976) was it possible for Seeman and Anderson to claim, "There is no compelling evidence that lack of control at work does, in fact, play an important role in generating an overall sense of powerlessness" (1983, 60). We also find that some of the job conditions in our analysis, specifically substantive complexity and job pressures, are correlated with diminished self-control over alcohol use among both men and women. But it is our covariance analyses that provide the findings most pertinent to the issues addressed in this chapter. Kohn argues that "the lessons of the job are directly generalized to nonoccupational realities" (1976, 127). This would seem to be the case for the alienated groups of men and women that are defined by the accretion of negatives. The men and women in the alienated groups appear to carry the lessons of the job with them to their behavior off the job. Not exercising self-direction in their

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work, not assessing themselves as having control over their lives, and not expecting much of themselves, they do not exercise considerable self-control over their alcohol use. But the generalization thesis seems less applicable to the other groups at risk for diminished self-control over alcohol than the fit thesis that jobs which are incongruent with the psychological orientations of some men and women are conducive to diminished self-control. The men in the burned-out group have job experiences which are too demanding for their impoverished sense of mastery and self-worth, and they have diminished control over their use of alcohol. The men and women in the unchallenged groups have job experiences with insufficient challenge and responsibility given their self-assessed capability for control over the events in their lives, and they also have diminished control over their alcohol use. Kohn and his associates have focused on job experiences which are devoid of initiative, thought, and independent judgment but not on job experiences which are either too demanding or lack sufficient challenge given the sense of powerlessness (or mastery) and self-estrangement of some men and women. Kohn and his associates have found that the lessons from undemanding conditions of the job are carried over to undemanding leisure activities such as long hours of watching television. We find, though, that not only do the lessons from alienating job conditions (and psychological orientations such as self-estrangement) appear to be generalized to drinking behavior but also that the lack of fit between certain job conditions and the self-assessed needs and capacities of some men and women appear to be conducive to alcohol use and abuse. We recognize, of course, that these relationships may involve reciprocal effects wherein complexity and the psychological alienations may affect and be affected by alcohol use, but we do not have data that would identify some of the equations in a reciprocal effects model. Our objective has been to determine whether support could be found for the generalization thesis and for the fit thesis that jobs which are incongruent with the needs and capacities of some men and women are conducive to the use and abuse of alcohol. Because we have found such support, further research of a longitudinal nature which would provide appropriate instrumentation for a causal analysis is warranted and should be carried out. IMPLICATIONS FOR PRACTITIONERS Workplace alcoholism programs, usually a component of broad employee assistance programs that offer help for problems other than alcoholism, have undergone considerable development (Blum, 1988). According to Roman and Blum (1985; Roman, 1988a), the core technology of such programs comprises seven elements: (1) identification of alcoholic employees on the basis of job performance problems; (2) provision of expert consultation to managers, supervisors, and shop stewards concerning employee alcohol abuse and other problems that affect job performance; (3) constructive confrontation, placing before al-

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coholic employees evidence of poor work performance in order to compel them to take steps to shape up; (4) creation of linkages between individual employees with substance-abuse problems and counseling or treatment services in the community; (5) establishment of organizational-level linkages between workplaces and service provider agencies in the community; (6) promulgation of the concept that the workplace can be a setting for providing assistance with alcohol and other substance-abuse problems; and (7) emergence of the role of the program coordinator as the organizational consultant on issues affecting employee welfare. One implication of our analysis is that the population of employed men and women who are appropriate targets of workplace programs are not necessarily those persons for whom there is evidence of poor job performance. As Roman has observed in connection with a related analysis of the Detroit data (Parker and Farmer, 1988), the implication is that "all employees with alcohol problems should be the target of workplace interventions; such reasoning may embed the classic disease model of alcoholism wherein it is plausible to expect that cases of alcohol problems at an early stage, prior to performance deterioration, are prodromal to eventual deterioration" (Roman, 1988b, 109). Because workplace programs use the technological tool of constructive confrontation based on evidence of impaired job performance, new procedures for reaching alcoholic employees who do not manifest impaired job performance need to be developed (see Reichman, Young, and Gracin, 1988). We have found that the exercise of self-direction in employment and the orientations of powerlessness (or mastery) and self-estrangement appear to be of critical importance for self-control over alcohol use. As Kohn has argued in reference to self-control in other areas of psychological functioning; "[A]cting on the basis of one's own judgment, attending to internal dynamics as well as to external consequences, being open-minded, being trustful of others, holding personally responsible moral standards—this is possible only if the actual conditions of life allow some freedom of action, some reason to feel in control of fate" (1969, 189). Another implication of our analysis is that increasing self-direction in employment and decreasing the sense of powerlessness and self-estrangement of employed men and women might reduce the risk of diminished self-control over alcohol use. Clearly there is a need for workplace program coordinators to have the scientific training necessary to serve as organizational consultants on issues of job redesign. Occupational rearrangements can change what the worker does on the job and thus change behavior in a way that gradually leads to a more positive set of attitudes about the nature of the work, the organization and its environment, and the self (Hackman and Suttle, 1977). Those program coordinators who are oriented toward only "rehabilitating the worker" and not also confronting the sources of alienation, burnout, and lack of challenge in the workplace may have only limited success in such a constrained role. Greater effectiveness may be possible with an expanded role that includes advising management and labor about job redesign since the findings from the analyses

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by Kohn (1976), Karasek (1979), and ourselves imply that those workplace interventions which give the worker meaningful control over the conditions of the job—real opportunities to exercise initiative, thought, and independent judgment in work—will decrease psychological alienations and thus reduce the risk of diminished self-control over alcohol use.

NOTE The data analysis in this chapter was supported in part by the National Institute on Alcohol Abuse and Alcoholism and by California State University, Long Beach. We thank Eve Weinberg, who was responsible for data collection; Martin R. Frankel, who developed the sampling design for our study; Thomas C. Harford, who gave us considerable encouragement and support; and Michael Wolz, who performed much of the computer programming required for the data analysis.

REFERENCES Blum, T.C. (1988). New occupations and the division of labor in workplace alcoholism programs. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 205-221). New York: Plenum Press. Cahalan, D., and Room, R. (1974). Problem drinking among American men. New Brunswick, NJ: Rutgers Center of Alcohol Studies. Cherniss, C. (1980). Staff burnout. Beverly Hills, CA: Sage Publications. Duncan, O.D. (1961). A socioeconomic index for all occupations. In A.J. Reiss (Ed.), Occupations and social status (pp. 109-138). New York: The Free Press. Edwards, G., and Gross, M.M. (1976). Alcohol dependence: Provisional description of a clinical syndrome. British Medical Journal, 1, 1058-1061. Hackman, J.R., and Suttle, J.L. (1977). Improving life at work. New York: Scott, Foresman and Company. Hilton, M.E. (1987). Drinking patterns and drinking problems in 1984: Results from a general population survey. Alcoholism: Clinical and Experimental Research, 11, 167-175. Jellinek, E.M. (1960). The disease concept of alcoholism. New Haven, CT: College and University Press. Jellinek, E.M. (1962). Phases of alcohol addiction. In D.J. Pittman and C.R. Snyder (Eds.), Society, culture and drinking patterns (pp. 356-358). New York: John Wiley. Karasek, R.A. (1979). Job demands, job decision latitude, and mental strain: Implications for job redesign. Administrative Science Quarterly, 24, 285-308. Kohn, M.L. (1969). Class and conformity: A study of values. Homewood, IL: The Dorsey Press. (2d ed., 1977, Chicago: University of Chicago Press.) Kohn, M.L. (1976). Occupational structure and alienation. American Journal of Sociology, 82, 111-130. Kohn, M.L. (1978). Discussion. Intramural Research Workshop on Occupational Conditions and Drinking Patterns, National Institute on Alcohol Abuse and Alcoholism. Summarized in D.A. Parker (1981), Job experiences and the use of alcohol

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during free time. In Leisure in crisis time (pp. 115-126). Antwerpen, Belgium: Foundation Van Cle. Kohn, M.L. (1987). Cross-national research as an analytic strategy. American Sociological Review, 52, 713-731. Kohn, M.L., and Schooler, C. (1973). Occupational experience and psychological functioning: An assessment of reciprocal effects. American Sociological Review, 38, 97-118. Kohn, M.L., and Schooler, C. (1982). Job conditions and personality: A longitudinal assessment of their reciprocal effects. American Journal of Sociology, 87, 12571286. Kohn, M.L., and Schooler, C. (1983). Work and personality: An inquiry into the impact of social stratification. Norwood, NJ: Ablex Publishing Corp. Marx, K. (1964). The economic and philosophic manuscripts of 1844. New York: International Publishers. Maslach, C. (1982). Understanding burnout: Definitional issues in analyzing a complex phenomenon. In W.S. Paine (Ed.), Job stress and burnout (pp. 29-40). Beverly Hills, CA: Sage Publications. Miller, A.R., Treiman, D.J., and Cain, P.S. (1980). Work, jobs, and occupations: A critical review of the dictionary of occupational titles. Washington, DC: National Academy Press. Parker, D.A., and Brody, J.A. (1982). Risk factors for alcoholism and alcohol problems among employed men and women. In Occupational alcoholism: A review of research issues (NIAAA Research Monograph No. 8, pp. 99-127). Washington, DC: U.S. Government Printing Office. Parker, D.A., and Farmer, G.C. (1988). The epidemiology of alcohol abuse among employed men and women. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 113-130). New York: Plenum Press. Parker, D.A., Kaelber, C , Harford, T . C , and Brody, J.A. (1983). Alcohol problems among employed men and women in metropolitan Detroit. Journal of Studies on Alcohol, 44, 1026-1039. Parker, D.A., and Maattanen, K. (1987). Intoxication and self-orientations during alcohol use: An empirical assessment of the relationship and of its determinants. Journal of Studies on Alcohol, 48, 443-449. Reichman, W., Young, D.W., and Gracin, L. (1988). Identification of alcoholics in the workplace. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 171-179). New York: Plenum Press. Roman, P.M. (1988a). Growth and transformation in workplace alcoholism programming. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 131-158). New York: Plenum Press. Roman, P.M. (1988b). Overview. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 105-111). New York: Plenum Press. Roman, P.M., and Blum, T.C. (1985). The core technology of employee assistance programs. Almacan, 15, 8-12. Seeman, M. (1959). On the meaning of alienation. American Sociological Review, 24, 783-791. Seeman, M., and Anderson, C.S. (1983). Alienation and alcohol: The role of work, mastery, and community in drinking behavior. American Sociological Review, 48, 60-77.

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Seeman, M., Seeman, A.Z., and Budros A. (1988). Powerlessness, work, and community: A longitudinal study of alienation and alcohol use. Journal of Health and Social Behavior, 29, 185-198. Straus, R. (1976). Problem drinking in the perspective of social change, 1940-1973. In W.J. Filstead, J.J. Rossi, and M. Keller (Eds.), Alcohol and alcohol problems: New thinking and new directions (pp. 29-56). Cambridge, MA: Ballinger Publishing Company. Tolbert, C , Horan, P.M., and Beck, E.M. (1980). The structure of economic segmentation: A dual economy approach. American Journal of Sociology, 85, 10951116. United States Department of Labor. (1965). Dictionary of occupational titles. Third edition. Washington, DC: U.S. Government Printing Office. United States Department of Labor. (1977). Dictionary of occupational titles. Fourth edition. Washington, DC: U.S. Government Printing Office. Wilensky, H.L. (1960) Work, careers, and social integration. International Social Science Journal, 12, 543-560.

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4 JOBS, OCCUPATIONS, AND PATTERNS OF ALCOHOL CONSUMPTION: A REVIEW OF LITERATURE JACK K. MARTIN

Systematic studies of job and occupational influences on patterns of workers' drinking behavior represent important contributions to the literature addressing problems of alcohol use, abuse, and treatment in American society. An understanding of these connections is critical to this inquiry for several reasons. It is widely recognized that the great majority of persons who experience or develop alcohol-related problems are nonetheless able to maintain relatively stable employment (Straus and Bacon, 1951; Plant, 1979; Parker and Farmer, 1988). This pattern of stable employment is particularly evident among problem drinkers found in the early and middle developmental stages of increasing abuse of alcohol (Archer, 1977b). Further, research indicates that work and familyrelated alcohol problems associated with heavy drinking are probably more widespread than previously conceived. Job-related alcohol problems of employed persons may occur episodically, even among individuals who do not follow a classic ''disease model" evolution of loss of control and alcoholism (Clark, 1976). Assuming that significant numbers of alcoholic and nonalcoholic workers alike experience at least occasional problems related to their drinking while employed, alcohol use by employees exacts significant social and economic costs (for employers and employees) associated with the lowered productivity, increased absenteeism, and impaired job performance of heavy drinkers (Roman and Trice, 1970; Von Wiegand, 1972). Beyond the realization that large numbers of workers today suffer from a variety of alcohol-related problems, it is also important to note that a substantial literature indicates that workers in certain occupations and types of workplaces are prone to a higher incidence of these problems (Cosper, 1979; Ojesjo, 1980). Explanations for these patterns have varied widely, but they emphasize the following:

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1. The self-selection (by problem drinkers) of occupations that either permit concealment or that have developed distinctive subcultures that encourage and support alcohol use (cf. Hitz, 1973; Schuckit and Gunderson, 1974; Plant, 1978, 1981) 2. The lack of social control and organizational constraints characteristic of specific jobs, occupations, and workplaces that would facilitate alcohol use by decreasing the visibility of the alcohol-impaired worker (cf. Roman and Trice, 1970; Mannello and Seaman, 1979; Roman, 1981; Schollaert, 1977) 3. The structural characteristics of certain kinds of jobs and workplaces that may encourage a reliance on alcohol as a coping mechanism (cf. Harris and Fennell, 1988; Martin, Blum, and Roman, 1989) The extent to which any or all of these factors have been found to relate to either the prevalence or distribution of alcohol problems in American industry underscores the importance of understanding these occupational influences on this multifaceted behavior. Subsequent sections of this chapter focus on the third variation of the jobs/occupations-alcohol use question described above. Specifically, the question of how characteristics of jobs influence the drinking behaviors of incumbents will be examined within the context of an emerging body of theory and research. Readers interested in the occupational selection/subcultures and the social control/organizational constraints literatures should refer to reviews by H. Trice and W. Sonnenstuhl (1989), K. Fillmore and R. Caetano (1982), D. Herold and E. Conlon (1981), R. Cosper (1979), M. Plant (1977), or J. Archer (1977a). EARLY STUDIES The Relationship of Occupational Status to Alcohol Problems As Roman (1981, 357) points out, the fascination of social scientists with the possibility of work-based causes of deviant behaviors runs deep. For example, in the United States studies of the epidemiology of alcohol problems and the workplace can be found going back 150 years or more (Fillmore and Caetano, 1982). Such interest in part derives from the long-standing and consistent association of various types of deviance and disease with social class and occupational memberships (Roman, 1981). These early studies are notable for several reasons. To begin, although several studies have demonstrated that problem drinking and alcoholism seem to be related to class positioning as measured by occupation, the patterns are by no means consistent. For example, among clinical or incarcerated populations, a positive association between occupational status and problem drinking is reported by R. Straus and S.D. Bacon (1951). More frequently, however, negative associations have been found between occupational status and problem drinking. This negative pattern has been reported in studies by R. Clark (1949), W. Scott (1954), D. Falkey and S. Schneyer (1957), F. Taylor (1957), A. Ullman et al. (1957), B. Malzberg (1960), D. Ethridge

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and J. Ralston (1967), M. Schuckit and E. Gunderson (1974), and J. Archer (1977b). Finally, three studies—by B. Chodorkoff, H. Krystal, and J. Nunn (1961), M. Carney and T. Lawes(1967), and J. Mayer and D. Myerson(1970)— report no relationship between occupational status and problem drinking. The fact that early studies of occupational variations in alcoholism have not yielded consistent patterns of relationships is hardly surprising when these studies are considered within the context of their methodological limitations. For example, since these early studies relied on populations of identified alcohol abusers found in clinical or institutional settings, the type of treatment center selected (e.g., private, public, or state hospital) to a large extent determined the class and occupational backgrounds of clients (Fillmore and Caetano, 1982). Greater numbers of the working and lower classes are likely to be found in public treatment centers and hospitals; middle- and upper-class alcoholics and problem drinkers are more likely to utilize relatively expensive private facilities. An additional methodological weakness that severely limits the utility of these studies relates to the absence of relevant comparison groups. Specifically, these early studies do not typically provide evidence relative to the occupational distribution of the larger population of workers in the community. For example, the finding that most identified alcoholics are found in lower skilled workingclass occupations may indeed reflect (as some have argued), the carryover or spillover effect of nonrewarding or stressful work typical of these occupations. On the other hand, this finding may simply reflect the fact that this is the largest occupational category in the community studied. Furthermore, studies such as those noted above, by focusing only on the relationship of broadly defined occupational categories (e.g., blue collar vs. white collar) to the rate of alcohol problems, provide little information with respect to the occupational characteristics of nonproblem-drinking workers who are found in those same categories. Finally, relative to this last point, by failing to consider variations in job and workplace characteristics within broader occupational categories, early studies of jobs, occupations, and alcohol consumption have rarely provided information useful for the creation of testable hypotheses. Indeed, these early studies are primarily descriptive or, at best, bivariate analyses. Occupational Risk Factors The early epidemiological studies of occupational and class variations in rates of problem drinking produced a modest body of basic information, along with a number of widely accepted, but untested theoretical assertions (Archer, 1977b). In particular, following from the accepted notion that alcoholism is a disease, workers were seen as entering the workplace with drinking problems (Parker and Farmer, 1988). Moreover, this argument was consistent with the popular suggestion that individuals with drinking troubles select occupations that allow concealment (Parker and Brody, 1982). As Parker and Farmer (1988) point out, however, selection arguments not only assume that workers have access to

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accurate information on job conditions typical of different occupations, but also imply that workers have the ability to choose freely among occupations when seeking employment. Neither assumption is necessarily supported by empirical research. More important, knowing generally that workers in lower status occupations are more likely to develop problems related to alcohol abuse begs the more important question of what it is about these occupations that might facilitate or motivate these problematic behaviors. In an attempt to move beyond these shortcomings of self-selection and epidemiological analyses of workers' drinking behaviors, attention was focused on the possible etiological connections between the individual's work and his or her pattern of alcohol consumption. An influential discussion of the work-based etiology of drinking behavior is found in the work of Roman and his associates (Roman and Trice, 1970; Trice and Roman, 1978; Roman, 1981). While generally viewed as an example of the social control position (e.g., some jobs and workplaces are structured so as to reduce the social and physical visibility of the problem drinker and as such lack meaningful social control mechanisms that mitigate against alcohol abuse), the Roman and Trice (1970) model of occupational "risk factors" also develops logic to indicate how certain characteristics of jobs might lead to a reliance on alcohol as a coping mechanism. For example, jobs characterized by low visibility also frequently imply isolation, freedom from supervisory feedback, and a general absence of structure that may be translated into feelings of anxiety and job stress, which in turn might be resolved through deviant drinking (Roman, 1981, 358). Furthermore, in a later formulation of this perspective, Trice and Roman (1978) point out that excessive work loads, competition among employees for resources, and so on are potentially stressful characteristics of jobs that might also promote a reliance on alcohol on the part of many workers. While never offered as a systematic theory of the work-based etiology of alcohol problems, Roman and Trice's (1970) discussion of occupational risk factors did provide researchers with what Blumer (1954) called a "sensitizing device" or a framework that could be used to examine broadly the job-related sources of deviant drinking. What was notable about this perspective was that it postulated job-to-individual effects in regard to alcohol use. In other words, the risk factor approach allows for the possibility that characteristics of certain jobs operate to motivate alcohol consumption. For the most part, empirical applications of Roman and Trice's (1970) risk factor framework have sought to verify the utility of this model in studies of job factors that are related to the identification of excessive or problem drinkers (cf. Schollaert, 1977; Parker, 1978; Roman, 1981). Less frequently the emphasis has been on the second component of this perspective (i.e., whether the lack of social and physical visibility generates stresses and anxieties that promote alcohol use). One study provides a notable exception. In an extensive study of employee alcohol problems in the railroad industry, Mannello and Seaman (1979) present data from a survey of over 4,600 workers. Not only did these researchers find

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evidence to support Roman and Trice's (1970) basic conceptualization that factors related to visibility were associated with problem-drinking status, but Mannello and Seaman (1979) also report data to support the notion that job structures may operate to promote alcohol use. For example, associations were found between problem drinking and work addiction (e.g., the amount of time the individual devotes to his or her job), perceived occupational obsolescence (e.g., the meaninglessness of the individual's job roles), perceived adequacy of job performance, and the degree of job satisfaction (Roman, 1981). Thus, Mannello and Seaman (1979) find evidence that characteristics of jobs are not only related to the identification of workers with alcohol problems but are also precursors to heavier amounts of drinking. RECENT THEORY AND RESEARCH: ALIENATION AND JOB STRESS GENERALIZATION MODELS Theorists and researchers who study work and workers have long argued that the work performed by adult members of society plays a significant role in shaping the individual's overall life quality, either positively or adversely (Hall, 1986). Moreover, classic (e.g., Karl Marx) and contemporary (e.g., H. Braverman) critics of work have raised the prospect that the traditional emphases of modern industries on improving the technical design of jobs and production processes have produced a situation wherein the physical and psychological needs of workers are ignored or neglected in the pursuit of ever-increasing productivity (cf. Shaiken, 1986; Braverman, 1974; Sheppard and Herrick, 1972). According to this point of view, modern work has become less rewarding and satisfying as jobs have become increasingly bureaucratized, routinized, fractionalized, depersonalized, and more repetitive. In classic terms, workers become alienated, experience feelings of powerlessness and nonengagement, and develop an instrumental orientation toward their work (Trice and Sonnenstuhl, 1989; Seeman and Anderson, 1983). These adverse effects of work on workers are assumed not only to be manifest in the job-related mental health and behaviors of workers (e.g., feelings of dissatisfaction, burnout, and noninvolvement) but also to have important effects on mental health and behavior in nonwork settings (e.g., family and community). This describes what has been characterized as an "alienation" (Parker and Farmer, 1988; Trice and Sonnenstuhl, 1989) or "generalization" (Martin, Blum, and Roman, 1989) perspective on worker behaviors. The primary concern of this model revolves around workers' subjective, psychological, and social responses to nonengaging work. The manner in which nonrewarding or alienating jobs generalize their supposedly negative effects to patterns of workers' drinking (not a question typically addressed by alienation theorists) is suggested in the preface to the now famous report, Work in America (U.S. Department of Health, Education and Welfare, 1973). According to this report, "as work problems increase, there may be a

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consequent decline in physical and mental health, family stability, community participation . . . while there is an increase in drug and alcohol addiction" (xvi). From the perspective of a theory of worker alienation, the disaffected worker psychologically withdraws from the nonrewarding world of work by daydreaming, becoming apathetic, denigrating work as an important personal activity, using alcohol and drugs as a buffer against the dehumanizing aspects of modern work and workplaces (Mangione and Quinn, 1975). Most recently, the generalization perspective has been developed in the work of Melvin Kohn and his associates (e.g., Kohn and Schooler, 1983, 1982, 1973; Miller et al., 1979; Kohn, 1980, 1976). According to Kohn, "the lessons of the job are directly generalized to nonoccupational realities" (1976, 127). One implication of this is that "alienation from work becomes alienation from life" (Wilensky, 1960, cited in Parker and Brody, 1982). Considerable empirical evidence supports this contention (Martin, Blum, and Roman, 1989). For example, A. Kornhauser (1965), R.W. Rice (1984), and R. Veehoven and T. Jonkers (1983) report positive associations between levels of job satisfaction and both overall life satisfaction and the absence of psychiatric symptoms. Studies by S.E. Jackson and C. Maslach (1982), P. Evans and F. Bartolome (1980), and C.S. Piotrkowski (1978) have found evidence that problems experienced on the job have important adverse effects on family structure and on at-home behavior. M.J. Kavanaugh, M. Hurst, and R. Rose (1981) report that among air traffic controllers job satisfaction was negatively related to five different types of independently evaluated psychosocial problems. Finally, Kohn and Schooler (1982) report evidence of several "job-to-personality effects, the most important being that oppressive working conditions produce a sense of distress" (1982, 1281) and that levels of job complexity are negatively related to feelings of anxiety (Kohn and Schooler, 1983). While there is substantial evidence that occupational and job characteristics have important consequences for individual psychological well-being and functioning (Mensch and Kandel, 1988), the question of why this is the case remains the subject of some debate. Proponents of the alienation or generalization perspectives indicate that for many employees work has been lost as an intrinsically important social activity or "central-life interest" (Trice and Sonnenstuhl, 1989). Drinking for these individuals is seen as a means of providing a mechanism for coping with or compensating for a loss of engagement (Trice and Sonnenstuhl, 1989). In recent years, however, an alternative modeling of the job-related sources of workers' drinking behavior has emerged around the issues of occupational and job-related stress. In many regards, stress-related models of worker behavior and alienation and generalization models are similar perspectives. For example, both emphasize very similar job characteristics (e.g., monotony, repetition, control of tasks, and job complexity) as having important effects on the psychological functioning and behavior of workers. Stress and alienation or generalization models differ in terms of ideology (Trice and Sonnenstuhl, 1989). Specifically, unlike alien-

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ation and generalization perspectives, job stress models do not make assumptions regarding the central importance of work in the individual's life. Rather, the job stress perspective holds that certain features of modern work are potentially and frequently stressful (e.g., working under time pressure, working at a demanding job, and working without decision-making power). For certain individuals, these stresses at work are likely to translate into distresses and strains experienced in nonwork contexts, regardless of whether the worker has a rewarding or engaging job (Trice and Sonnenstuhl, 1989). Indeed, work stress researchers point out that the mental and physical health of both disaffected assembly-line workers and highly satisfied executives can be negatively affected by the presence of jobrelated stress (Karasek, 1979). Since they are primarily empirical (Trice and Sonnenstuhl, 1989), work stress perspectives have identified a wide variety of undifferentiated job stress-related causes of physical and psychological distress (Karasek, Gardell, and Lindell, 1987): machine pacing, monotony, decision-making latitude, physical and mental demands, economic pressure, and role conflicts. For the most part, the job stress perspective does not represent a systematic theory as such. Rather, this perspective, like Roman and Trice's earlier (1970) formulation of occupational risk factors, provides a set of job-based independent correlates that may affect the mental and physical health (at work, at home, and in the community) of certain individuals. It is interesting to note, however, that the alienation model and the stress perspective are alike in at least two important regards. First, both perspectives allow that disaffection from work or the presence of adverse working conditions will have a variety of negative psychological and physical effects on workers, and that these effects will frequently carry over to attitudes and actions in nonwork settings. Second, and most important, when proponents of both perspectives have developed logic that attempts to understand the job-related correlates of problem drinking, they arrive at a very similar conclusion. Specifically, both perspectives posit that certain workers come to rely on alcohol as a means of changing their psychological condition, covertly coping with the negative aspects of the job via alcohol use. This behavior (particularly at heavier levels of consumption), although positively reinforcing in the short run, operates to place the worker at greater long-term risk for illness, job loss, and alcoholism (Conway et al., 1981). Seen in this light, ideological differences regarding the proper place of work in the adult's life aside, both alienation and stress perspectives lend potentially valuable insights into the dynamic interplay of jobs, occupations, workplaces, and patterns of problem drinking. The hypothesized link between abusive levels of drinking and nonengaging or stressful employment, although seemingly logical and easily derived from established sociological and psychological theory, has only recently emerged as the focus of systematic investigation. For the most part, early, primarily correlational analyses of this connection operated from a stress model. These studies, which tended to examine alcohol use as only one of a variety of possible responses

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to stressful conditions, did not always find important positive associations between job stress and alcohol intake or abuse. For example, in a study of a national sample of American workers, G.L. Margolis, W.H. Kroes, and R.P. Quinn (1974) found evidence that several of ten indicators of job strain (including a measure of escapist drinking) were significantly associated with increased levels of job stress and lower reported satisfaction with work. These findings provide at least partial support for the hypothesized connection. It is appropriate to note, however, that the relationships reported by Margolis, Kroes, and Quinn (1974), although statistically significant and in the predicted directions, were small in magnitude. Similar minor effects of stress on the use of alcohol are reported in L. Pearlin and C. Radabaugh's (1976) study of 2,300 inhabitants of the Chicago metropolitan area. In this study, economic hardship (a dimension of stress that presumably is partially the consequence of having a less rewarding, lower status occupation) was significantly associated with heightened feelings of anxiety and increased drinking to relieve distress. These authors point out, however, that even among individuals who reported intensive anxiety, the vast majority (59 percent) were not likely to turn to alcohol for relief (Pearlin and Radabaugh, 1976, 658). Additionally, as Roman (1978) indicates in his reanalysis of these data, since Pearlin and Radabaugh's (1976) data are cross-sectional, the possibility that a reliance on alcohol to cope precedes economic stress cannot be ruled out. Of course this criticism applies equally well to a large number of survey analyses (e.g., Margolis, Kroes, and Quinn, 1974), and can be resolved only via more sophisticated analytical techniques (e.g., two-stage least squares) and the use of longitudinal designs. Interestingly, two of the few published longitudinal studies that examined the link between job stress and alcohol consumption were unable to support predicted relationships. In an eight-month study of U.S. naval personnel, Conway et al. (1981) report that not only was stress perception not significantly associated with chronic alcohol consumption, but moreover, in their sample alcohol intake was highest during periods of lowest job stress. This finding is counter to the expectations of the occupational stress framework. Similarly, B.S. Mensch and D. Kandel (1988), utilizing data from the Youth Cohort of the National Longitudinal Study of Labor Market Experience (NLS), report that, in a multivariate analysis, indices of several stress-producing dimensions of jobs were not significantly associated with the frequency of using various types of substances, including alcohol. These authors do find, however, that the highest use of these substances is found among workers who hold jobs that offer little opportunity for autonomy but simultaneously make excessive physical and psychological demands on the worker. This is an important finding since it is consistent with recent elaborations and verifications of the job stress perspective as regards the physical health of workers (cf. Karasek, 1979; Karasek et al., 1988). The finding that characteristics of jobs are not meaningfully related to increased use or reliance on alcohol, reported by T. Conway et al. (1981) and by Mensch

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and Kandel (1988), should be interpreted cautiously. For example, the rather unique nature of the sample employed in the Conway et al. (1981) study severely limits the extent to which the findings can be generalized to the larger population of workers. All respondents in this study were naval officers who had recently completed training and assumed command functions. In many regards, the ability of these individuals to use alcohol was restricted during this period of time. The lack of connection between jobs and drinking reported in the Mensch and Kandel (1988) data may also derive from limitations imposed by the NLS sample (e.g., all respondents were relatively young), but they are also suspect given the nature of the measures of job stress used in this analysis. As these authors indicate, their data do not provide for individual assessments of especially stress-producing job dimensions (e.g., repetition, pressure, and so on) (Mensch and Kandel, 1988, 172). Instead, these features of work are measured indirectly by assigning mean levels of complexity, skill, demands, and undesirable conditions to broad occupational categories. As Mensch and Kandel (1988, 181) point out, this approach does not capture the within-occupation variation in these stress-related dimensions. This approach to measurement, by assuming a homogeneity of job characteristics within occupations, probably attenuates the magnitude of the associations that can be obtained in these data. Recently, the link between characteristics of jobs and workers' drinking behaviors has been the topic of several studies. This research, which operates from both stress-based and alienation perspectives, is notable for at least two reasons. First, since drinking by workers is the primary focus of these studies, this inquiry represents a more systematic attempt to verify the hypothesized work-related influences on alcohol-specific behaviors. Second, these recent investigations are distinctly multivariate, allowing for the assessment of the relative importance of different classes of work characteristics as they contribute to the various forms of alcohol use. One of the first of these more systematic treatments of job-related influences on workers' drinking was conducted by M.L. Fennell, M.B. Rodin, and G.K. Kantor (1981). Using data obtained from the 1973 Quality of Employment (QES) Cross-section, these researchers examined two dimensions of alcohol use, the simple frequency of self-reported drinking, and seven reasons for drinking that were aimed at alleviating unpleasant emotional states (what are frequently referred to as escapist reasons for drinking). Examining the relationship of each drinking dimension to eight different hypothesized stress-producing characteristics of jobs (e.g., not having enough time, experiencing conflicting demands at work, and not receiving enough information), the authors provide marginal support for a stress generalization perspective. For example, alcohol intake was higher for workers who, regardless of age, education, gender, and occupation, reported not having enough time to complete job tasks and workers who felt promotions were not being handled fairly. Additionally, Fennell, Rodin, and Kantor (1981) find that each of the seven escapist reasons for drinking was given

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more frequently by workers who indicated the presence of stress-inducing job characteristics. Indeed, seven of the eight stressful conditions examined were significantly related to five or more escapist reasons, net of demographic controls. As T. Blum (1984) points out, the Fennell, Rodin, and Kantor (1981) findings that time pressure and perceived unfairness are associated with increased alcohol use provide little substantive support for the stress model of workers' drinking. The obtained effects are very small, and the implicit assumption that increased frequency of drinking is necessarily an adequate measure of problematic behavior is questionable. The second finding, however, that job stress may eventuate in individual definitions favorable to escapist uses of alcohol provides more compelling support for a generalization model, and this has provided the impetus for subsequent research. Two recent analyses of the connection of jobs to drinking reasons and alcohol consumption illustrate the importance of the earlier Fennell, Rodin, and Kantor (1981) finding. In a study of 261 white-collar employees from two corporate headquarters, M. Harris and M.L. Fennell (1988) find clear support for the hypothesis that the relationship of job stress to alcohol consumption is indirect, operating through escapist reasons for drinking. In particular, work overload was found to be an important source of these reasons for drinking, and, more important, workers reporting escapist reasons for their drinking consumed significantly greater amounts of alcohol. As hypothesized by these authors, estimates for the direct effects on consumption of the two types of job stress examined were not significant. Additional evidence of the importance of including reasons for drinking in models of the job-related influences on alcohol consumption is provided by the research of J.K. Martin, T. Blum, and P. Roman (1989). Embedded in their larger analysis of job-related influences on problem drinking, these authors report estimates for the direct and indirect influences of several job characteristics as they affect self-reported escapist reasons for drinking and frequency of drinking. These analyses (which utilized the 1973 QES Cross-section), yielded several interesting findings. To begin, in this research, each of the five job characteristics that were derived from alienation (levels of autonomy, extrinsic rewards, and closeness of supervision) and stress (work overload and physical effort) perspectives were found to have important indirect or direct effects on the dependent variables, although the patterns were significantly different for men and women. For men, only one job dimension, levels of physical effort required on the job, had a significant direct effect on consumption, net of reasons for drinking and several demographic controls. Levels of autonomy, overload, and extrinsic rewards, however, did produce significant indirect effects on consumption through escapist reasons for drinking. Moreover, the total effects of these variables were in the hypothesized directions. It is interesting to note that the Martin, Blum, and Roman (1989) analysis found clear evidence that the form of the jobs, reasons for drinking, and alcohol consumption relationship was not the same for women and men. For women

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workers in the QES, only two of the job characteristics, levels of autonomy and the closeness of supervision, were found to significantly influence alcohol consumption. Unlike men, these were direct effects on consumption. Indeed, none of the five job characteristics produced important indirect influences since none were significantly related to the presence of escapist reasons for drinking. For women, individual (e.g., age, marital status) and demographic (place of residence) factors appear to be the primary sources of these attitudes toward the uses of alcohol. The realization that the job-related influences on workers' drinking behavior may be different for employed women and men is further emphasized when the focus of the analysis is problem-drinking behavior. Defining problem drinkers as workers who consumed at the heaviest levels and who also reported escapist reasons for their consumption, Martin, Blum, and Roman (1989) found that among men, low levels of material rewards (e.g., wages and fringe benefits) and high levels of work pressure and overload were significant predictors of problem-drinking status. Consistent with the earlier finding regarding the jobrelated influences on the frequency of alcohol consumption for women, individual and demographic attributes, not job characteristics, were the primary correlates of problem drinking. These gender differences in alcohol consumption and problem drinking notwithstanding, the Martin, Blum, and Roman (1989) analysis provides support for both alienation and occupational stress models of alcohol consumption. The research of D. Parker and his associates (Parker et al., 1983; Parker and Brody, 1982; Parker and Farmer, 1988. 1990) provides additional support for occupational stress and alienation models of the job-related influences on workers' drinking behavior. In a series of studies utilizing a random sample of 1,367 Detroit area employed men and women, these authors have conducted several analyses of a variety of the different forms of alcohol use and abuse. These include frequency of bar patronage, volume of alcohol consumption, psychological dependence on alcohol (e.g., drinking for escapist reasons), symptomatic drinking (e.g., drinking first thing in the morning), loss of control over alcohol (e.g., not being able to stop drinking before becoming intoxicated), and job problems related to drinking (e.g., not going to work due to hangover, drinking on the job). In a study of four of these alcohol problems, Parker and Brody (1982) found evidence that variables associated with alienation (job complexity) and stress (perceived job stress) perspectives had important effects on psychological dependence, loss of control, symptomatic drinking, and alcohol-related job problems. Like Martin, Blum, and Roman (1989), these authors find evidence of some gender differences in the nature of these relationships. Among men, lower levels of complexity were significantly related to an increased psychological dependence on alcohol. For both women and men, low levels of complexity were associated with problems with alcohol on the job. Perceived job stress was also found to be related to three of the four alcohol problems. Among men, high stress was

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associated with psychological dependence, loss of control, and the presence of job-related problems. For employed women, stress was significantly related to psychological dependence, loss of control, and symptomatic drinking behavior. It is interesting to note that Parker and Brody (1982) found that the sources of job stress were different for men and women. Men who reported high levels of time pressure and low levels of complexity were more likely to perceive their jobs as stressful. Women, on the other hand, were more likely to perceive stress at work when they experienced time pressure, routinization of tasks, and high levels of visibility of job performance. In later analyses of these data, Parker and Farmer (1988, 1990) provide additional evidence of job-related influences on workers' drinking. In support of assumptions derived from an alienation model, Parker and Farmer (1988) found that lower levels of job complexity were significantly related to both symptomatic drinking and alcohol abuse as defined by physiological dependence, loss of control, frequency of intoxication, belligerence, and job disruption. This pattern, evidenced for employed men and women, retained significance in spite of controls for stress, demographic attributes, and a large number of job, workplace, and industry characteristics. Similarly, net of these controls, perceived job stress was associated with higher levels of symptomatic drinking, although stress (unlike complexity) was not found to have an important effect on the levels of alcohol abuse. Even though the relationships obtained in the research of Fennell, Rodin, and Kantor (1981), Harris and Fennell (1988), Martin, Blum, and Roman (1989), Parker and Brody (1982), and Parker and Farmer (1988) are generally supportive of occupational stress and alienation models of workers' drinking, this is not to suggest that all studies have found similar support. In particular, the research of M. Seeman and C. Anderson (1983) and M. Seeman, A. Seeman, and A. Budros (1988) questions the utility of alienation perspectives on these behaviors. Seeman and Anderson (1983) examined patterns of three different drinking behaviors (frequency, servings consumed, and drinking problems) in a random sample of 450 working- and middle-class residents of Los Angeles. In their analysis of these data, Seeman and Anderson (1983) find that social-psychological alienation (measured as feelings of powerlessness and low self-mastery) has a powerful effect on each dimension of drinking. Several characteristics of jobs derived from an alienation model (e.g., complexity, satisfaction with intrinsic job rewards, and overall job satisfaction), that were predicted to have independent effects on drinking, however, were not important sources of these behaviors. Moreover, these authors found no evidence that these job conditions were indirect sources of drinking behaviors since levels of powerlessness were not found to be related to the presence or absence of alienating job conditions. Seeman and Anderson (1983) interpret these data to reject the work alienation model as it regards a carryover to the sources of drinking behaviors. In a later replication and extension of the earlier Seeman and Anderson (1983) analysis, Seeman, Seeman, and Budros (1988) report the results of a longitudinal

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and cross-sectional study of alienation and alcohol use. Respondents from the original sample were reinterviewed following a four-year interval (n = 172), along with an additional 333 respondents who were not members of the original sample. The pattern of the relationships reported in this later analysis was interpreted to be broadly supportive of the earlier finding that factors related to alienation from work were not important sources of the three indicators of alcohol use examined. As before, only feelings of powerlessness emerged as an important source of drinking behaviors. It is important to note that the measure of work alienation used in this later study is not the same as that utilized in the previous study. In the earlier (1983) study, work alienation was operationalized as low levels of job complexity (measured as more or less objective features of the respondent's occupation); in the later (1988) study, however, alienation from work is taken as low levels of perceived decision latitude (essentially a self-report of opportunities for independent decision-making and skill utilization that is based in a measure developed by Karasek, 1979). Given these differences in measurement, the two sets of findings are not strictly comparable. The work of Seeman and his associates brings into question the efficacy of an alienation from work explanation of workers' drinking behaviors. It is appropriate to note, however, that this research has been the subject of critical review. For example, T. Blum (1984) raises important questions regarding the adequacy of Seeman and Anderson's (1983) measures of drinking behavior, particularly the elimination of nondrinkers from the analysis. Similarly, Parker and Farmer (1990) have questioned the adequacy of the measures of work alienation in the Seeman and Anderson (1983) research. Partly in response to the Seeman and Anderson (1983) and Seeman, Seeman, and Budros (1988) analyses, a recent study finds evidence that indicates that the alcohol-related effects of nonengaging or stressful jobs are more complex than previously conceived. In a reanalysis of their Detroit data, Parker and Farmer (1990) argue that it is an interaction of job characteristics and feelings of powerlessness that affects the alcohol problems of workers. Briefly, these authors indicate higher levels of problematic and impaired control over alcohol among workers who (1) experience low levels of complexity and low levels of personal mastery (a group of alienated workers), (2) experience low levels of complexity and high levels of mastery (unchallenged workers), or (3) experience high levels of complexity and low levels of personal mastery (burned-out workers). Moreover, Parker and Farmer (1990) find evidence of these same three groups of workers at risk for alcohol problems in the data of Seeman and his associates. Parker and Farmer's (1990) findings provide support for both work alienation and stress perspectives. The work alienation perspective finds obvious support in the higher levels of alcohol problems for the alienated and unchallenged groups, but is also supported by the finding that, regardless of gender, levels of job complexity and work pressure are associated with diminished control over alcohol (Parker and Farmer, 1990). A stress generalization model finds support in the finding that alcohol problems are greater among workers who experience

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high levels of complexity and low levels of personal mastery (burned-out workers). Theoretically such a contingency will be stressful for the individual involved. Indeed, Parker and Farmer (1990) indicate that in their sample, being a burned-out worker was not only associated with alcohol problems, but also with greater perceptions of job competition, time pressure, and job stress. On balance, generalization perspectives operating from either work alienation or occupational stress assumptions find modest, if not always consistent, support in the recent studies of workers' drinking behavior reviewed so far in this chapter. The final sections of this chapter build on this basic finding and offer suggestions for subsequent research. SUGGESTIONS FOR RESEARCH The focus of theory and research examining the connection of jobs and occupations to workers' drinking has changed dramatically over time (Fillmore and Caetano, 1982). Initial studies of occupational selection and subcultures have been replaced by theoretically driven models of the job-related sources of these multifaceted behaviors. It remains, however, that the majority of discussions of work and alcohol problems are concentrated on issues of intervention and treatment rather than etiology (Roman, 1981). It is only recently that systematic attention has been focused on the workplace as a possible contributory factor in bringing about these problems. These recent analyses, although they point to a variety of job-related influences on alcohol use, are by no means conclusive. Much in the way of additional research on these influences is needed at this point. To begin, it is difficult to reconcile contradictory findings (e.g., Seeman and Anderson, 1983), given the wide variety in types of samples (e.g., size and population), measures of job characteristics (e.g., subjective vs. objective measures, single-item vs. multi-item scales), and model specification (e.g., not controlling for relevant background factors) (Mensch and Kandel, 1988). Needed at this point is research that examines more or less standard measures of occupational, job-related, and social/demographic characteristics as they influence patterns of alcohol problems of workers in large representative samples of the labor force (Martin, Blum, and Roman, 1989). Related to this point, whenever possible these connections should be examined over time with longitudinal data bases. The vast majority of studies of the job-related influences on workers' problems with alcohol, since they are cross-sectional, have relied on logical criteria in assessing the effects of jobs on drinking. That is to say, problem and nonproblem-drinking workers are compared with respect to a variety of employment dimensions with obtained differences in drinking behavior interpreted as partial outcomes of differences in jobs. While common, post hoc analyses of this sort preclude needed examinations of temporal order (e.g., does problem drinking precede or follow deteriorating job conditions) or the long-term effects of nonrewarding or stressful employment on drinking behavior.

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In order to extend occupational stress and alienation explanations of workers' drinking behavior, subsequent research should move away from measures of this behavior which view level of consumption as a sine qua non for the presence of alcohol-related problems (Martin, Blum, and Roman, 1989). Too often this approach blurs the distinction between socially acceptable levels of alcohol use and deviant patterns of maladaptive alcohol abuse (Blum, 1984). This realization is critical for studies of the job and occupational influences on workers' drinking. Unlike other forms of workplace deviance (e.g., employee theft, sabotage, and excessive absenteeism), drinking per se is not a prima facie measure of workplace problems. In fact, many studies of workers' drinking find levels of consumption well within the range of ordinary or nonproblematic drinking (Blum, 1984). Logically, it is the extraordinary or problem forms of drinking that alienation and stress models seek to explain. By focusing on different forms of problem drinking, the recent studies of Parker and Farmer (1988, 1990) and Seeman and Anderson (1983) represent important steps in this direction. Similarly, a potentially important area for additional research is suggested in the Harris and Fennell (1988) and Martin, Blum, and Roman (1989) analyses of workers' reasons for drinking. Unpleasant job characteristics may indirectly influence problem-drinking behaviors by conditioning individual definitions of alcohol use as a coping mechanism or stress moderator. In other words, using alcohol off the job may provide the worker with an instrumental mechanism for escaping, forgetting, or redefining the effects of nonrewarding or stressful on-the-job experiences. A substantial literature (Pattison and Kaufman, 1982) describes such instrumental uses of alcohol as problematic since it is one component of the course toward alcohol dependency. Studies attempting to untangle these complex direct and indirect relationships between jobs, reasons for drinking, and problematic alcohol behaviors would significantly extend our understanding of the manner in which experiences on the job generalize their effects to nonoccupational settings. Finally, alcohol and workplace researchers need to broaden alienation and occupational stress perspectives by explicitly considering the role of worker characteristics in the generalization process. A growing body of theory and research in the sociology of work indicates that as a function of different job values and job needs, groups of workers (e.g., women, blacks, young workers) vary significantly in their attitudinal and behavioral responses to a number of job characteristics (cf. Martin and Hanson, 1985; Janson and Martin, 1982). Seen in this light, worker responses to employment are the result of an interaction between what workers value or expect and what jobs can provide. The utility of this approach, described as a "fit" (Hanson, Martin, and Tuch, 1987) or as a "dispositional" (Gruenberg, 1980) perspective, for studies of workers' drinking behavior is suggested by the finding that job characteristics influence the problem drinking of men, but not of women (Martin et al., 1989), and by Parker and Farmer's (1990) suggestion that a discrepancy between self-assessed needs and capacities and the characteristics of the individual's job appears to be a

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source of alcohol abuse. It remains for future research to specify more clearly the attitudinal and behavioral dynamic implied in a fit approach to the job-related influences on patterns of alcohol use of different groups in the labor force. CONCLUSIONS Despite a growing body of research documenting the influence of workplace characteristics on workers' drinking behavior, theorists and researchers continue to debate the importance of these factors in the etiology of alcohol abuse. One study (Plant, 1979) argues that current occupation exerts the most important influences on individual drinking patterns and problem drinking. Other research (Mensch and Kandel, 1988, 184) concludes that substance abuse (including alcohol) results more from the attributes of the workforce than the conditions in the workplace. The actual relationship is probably found between these opposing points of view. It is not the conclusion of this literature review that workplace factors are the primary causes of alcohol problems. Obviously, a massive literature points to the important influences on drinking behavior of biological factors, personality attributes, and family relationships. The understanding that the sources of alcohol abuse are multifactorial, however, should be tempered by the realization that outside of the family, the workplace is the primary social environment that can contribute to the development of maladaptive uses of alcohol (Straus, 1976). Indeed, since the factors that contribute to alcohol abuse and problem drinking remain unclear, in-depth examinations of a specific set of precursors (in this case, job and occupational dimensions) are preferable at this point to more ambitious studies that seek to identify the entire range of correlates (Gupta and Jenkins, 1984). Alcohol treatment specialists will find the debate regarding the relative importance of workplace etiological factors less interesting than will their counterparts in the academy. The data seem to indicate clearly that the various forms of problem drinking are at least modestly affected by the pressures of job expectations that exceed individual stress thresholds, and the estrangement from the social matrix experienced by many workers who find their jobs to be unchallenging and nonrewarding. Workplace interventions can benefit from this understanding. The remedial strategies that might be attempted would include (1) providing early help to targeted groups of workers shown to be at particular risk for developing maladaptive uses of alcohol as a coping mechanism (e.g., men in low-paying occupations, men in high-pressure jobs) (Ojesjo, 1980), (2) paying more attention to the selection and placement of workers in jobs that are consistent with individual job expectations and capabilities, and (3) implementing job redesign programs aimed at reducing the psychological demands of work or increasing the worker's opportunity to exercise self-direction, initiative, and independent judgment on the job (Parker and Farmer, 1990). Workplace interventions of this sort provide one of the more effective arenas for the secondary prevention of alcohol problems (Roman, 1981; Ojesjo, 1980).

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NOTE The author acknowledges postdoctoral fellowship support at the University of Georgia from Training Grant T32-AA-07473 from the National Institute on Alcohol Abuse and Alcoholism.

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Plant, M. (1977). Alcoholism and occupation: A review. British Journal of the Addictions, 73, 309-316. Plant, M. (1978). Occupation and alcoholism: Cause or effect? A controlled study of recruits to the drink trade. International Journal of Addictions, 13, 424-435. Plant, M. (1979). Drinking careers, occupations, drinking habits and drinking problems. London: Tavistock. Plant, M. (1981). Risk factors in employment. In B. Hore and M. Plant (Eds.), Alcohol problems in employment (pp. 10-19). London: Croom Helm. Rice, R.W. (1984). Organizational work and overall quality in life. In S. Oskamp (Ed.), Applied social psychology annual (Vol. 5). Beverly Hills, CA: Sage. Roman, P. (1978). Possible effects of using alcohol to control distress: A reanalysis of Pearlin and Radabaugh's data. American Journal of Sociology, 83, 987-991. Roman, P. (1981). Job characteristics and the identification of deviant drinking. Journal of Drug Issues, 11, 357-364. Roman, P., and Trice, H., (1970). The development of deviant drinking behavior. Archives of Environmental Health, 20, 424-435. Schollaert, P. (1977). Job-based risks and labor turnover among alcoholic workers. In C. Schramm (Ed.), Alcoholism and its treatment in industry (pp. 177-185). Baltimore, MD: Johns Hopkins University Press. Schuckit, M., and Gunderson, E. (1974). The associations between alcoholism and job type in the U.S. Navy. Quarterly Journal of Studies on Alcohol, 35, 557-585. Scott, W. (1954). Recorded inebriety in Wisconsin: An analysis of arrested inebriates in two Wisconsin counties. Sociology and Social Research, 39, 104-111. Seeman, M., and Anderson, C, (1983). Alienation and alcohol: The role of work, mastery, and community in drinking behavior. American Sociological Review, 48, 60-77. Seeman, M., Seeman, A., and Budros, A. (1988). Powerlessness, work, and community: A longitudinal study of alienation and alcohol use. Journal of Health and Social Behavior, 29, 185-198. Shaiken, H. (1986). Work transformed. Lexington, MA: Lexington Books. Sheppard, H.L., and Herrick, N. (1972). Where have all the robots gone? Worker dissatisfaction in the 70s. New York: Free Press. Straus, R. (1976). Alcoholism and problem drinking. In R. Merton and R. Nisbet (Eds.), Contemporary social problems (4th ed., pp. 183-217). New York: Harcourt, Brace, Jovanovich. Straus, R., and Bacon, S.D. (1951). Alcoholism and social stability: A study of occupational integration of 2,023 male clinic patients. Quarterly Journal of Studies on Alcohol, 12, 231-260. Taylor. F. (1957). A study of white male alcoholic patients, admitted to Connecticut State hospitals during the fiscal year 1956. Connecticut State Medical Journal, 21, 703-706. Trice, H., and Roman, P. (1978). Spirits and demons at work (2nd ed.). Ithaca, NY: Cornell University. Trice, H. and Sonnenstuhl, W. (1988). Workplace risk factors and drinking behavior: Implications for research and prevention. Journal of Applied Behavioral Science, 24, 327-346. Ullman, A., Demone, H., Steams, A., and Washburne, N., (1957). Some social char-

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acteristics of misdemeanents. Journal of Criminal Law and Criminology, 48, 4453. U.S. Department of Health, Education and Welfare. (1973). Work in America. Cambridge, MA: MIT Press. Veehoven, R., and Jonkers, T. (1983). Data-book on happiness. Dordrecht, Netherlands: Reidel. Von Weigand, R. (1972). Alcoholism in industry (USA). British Journal of the Addictions, 67, 181-187. Wilensky, H. (1960). Work, careers, and social integration. International Social Science Journal, 12, 543-560.

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5 MICROSOCIAL PROCESSES IMPACTING ON ALCOHOL PROBLEMS OVER WORK CAREERS JUDITH A. RICHMAN

INTRODUCTION: A PSYCHOSOCIAL FRAMEWORK From the perspective of linking prevention and intervention orientations, this chapter elaborates a psychosocial etiologic model currently being operationalized and empirically tested in relation to one occupation, that of medicine. Central to this model is the question of the relative salience of earlier social experiences and personality attributes which individuals bring to the occupational training and work environment on the one hand, and the social characteristics of medical training and work as they impact on problem-related drinking over work careers on the other hand. The study involves a longitudinal cohort investigation of drinking patterns of male and female medical students from entrance into medical school through a portion of the third year of training. The longer term study goal is to follow this student cohort through the remainder of medical school and residency training and into physician work careers. Although this research focuses on the profession of medicine, the theoretical framework and central questions addressed have implications for other occupational settings. First, as D.A. Parker and G.C. Farmer (1988) have suggested, many alcohol intervention programs in work settings have been premised on the assumption that men and women bring their (pre-existing) alcohol-related vulnerabilities to the workplace. However, an alternative causal model suggests that the social characteristics of work environments have important etiologic significance for the development and course of alcohol-related problems of workers. In addition, to the extent that particular structural features of medical training and work are linked to the development and course of drinking-related problems, we might speculate on the generalizability of our findings for other occupations sharing similar social characteristics. Some of these characteristics of particular

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relevance to medicine are the propensity for work addiction elaborated by P.M. Roman and H.M. Trice (1970), the presence of overwhelming work responsibilities and time involvement elaborated by Straus (1976), and the changes in social status and organization of an occupation which will be elaborated here.

THEORETICAL MODEL FOR THE STUDY OF AN OCCUPATIONAL GROUP: THE CASE OF (FUTURE) PHYSICIANS Our focus on future physicians grew out of the recent social concern over substance abuse by impaired physicians. A proliferation of articles in the medical and general media has highlighted the high (estimated) levels of problem drinking and other manifestations of distress in physicians which are likely to interfere with what is generically labeled the "reasonable performance of medical activities" (Coste, 1978; Pfifferling, 1981; Talbott and Benson, 1980). Epidemiologically, it is not clear that alcoholism and alcohol-related problems are more prevalent among physicians than other occupational groups (Niven, 1984). Yet, medicine represents a profession in which any level of drinking-related impairment may constitute a serious hazard for its clientele (i.e., patients) as well as for the physicians themselves (Clark et al., 1987). The greater current visibility of impaired physicians grows out of a societal milieu that has increasingly questioned medical priorities and practices as evidenced by the malpractice lawsuit crisis (Flaherty and Richman, 1986). However, although alcoholic physicians are currently more visible (and more likely to be channeled into treatment), little is known about the drinking behavior of the profession as a whole, the particular psychosocial determinants of physician drinking and alcohol-related problems, or the progression of drinking over time from the pretraining period through the various stages of training and medical practice. This chapter addresses the psychosocial etiology of drinking by future physicians in terms of a multidisciplinary set of variables encompassing earlier childhood experiences and individual psychological attributes, on the one hand, and structurally relevant attributes of medical training environments involving stressors and the availability of social supports, on the other hand. During the past decade, a series of psychosocial epidemiologic investigations of the occurrence and etiology of psychiatric disorders has led to the development of a model that identifies three major psychosocial components in the disease process: social stressors, external coping resources, and internal coping resources (Brown and Harris, 1978; Dohrenwend and Dohrenwend, 1981). In terms of the classic epidemiologic agent-host-environment triad, noxious role-related stressors such as those tied to work roles constitute the agent component, and external and internal resources constitute the environment and host components, respectively. Thus, the psychological damage inflicted by work-related psychosocial agents is seen to vary in magnitude, depending on intrapsychic susceptibility or resis-

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tance to particular stressors and depending on environmental social supports which may buffer or cushion the consequences of exposure to stressors (Susser, Hopper, and Richman, 1983). Prior research on physician alcohol consumption has focused primary attention on those physicians already identified as alcoholics and in treatment (Bissell and Jones, 1976; Johnson and Connelly, 1981). Notable exceptions, however, are found in G.E. Vaillant's et al. (1972) classic prospective longitudinal study, which shows that physicians manifest higher levels of substance abuse and of general distress and marital discord compared to controls, and C.V. Thomas, P.B. Santora, and J.W. Shaffer's (1980) longitudinal study of physician drinking in relation to overall health. These studies, begun prior to the large-scale entrance of women into medicine, focused on male physicians. Utilizing psychosocial perspectives, their primary etiologic focus involved intrapsychic vulnerabilities derived from earlier childhood experiences. Vaillant and associates found that the psychopathological differences between the physicians and the contrast group disappeared when childhood familial environment was controlled. The physicians subject to distress had depicted childhoods characterized by parental overprotection yet with limited emotional support and nurturance. Although Thomas and Duszynski (1974), in their prospective study of several cohorts of medical students, found that the groups later committing suicide or manifesting psychiatric disorders were somewhat more likely than the controls to have characterized their childhood familial relationships as involving emotional distance and matriarchal dominance, this family constellation did not predict frequency of alcohol consumption (Thomas, Santora, and Shaffer, 1980). However, it is conceivable that the suicide group in part reflected underlying alcoholism. Apart from the study of physicians per se, the psychosocial alcohol literature as a whole has pointed to early familial experiences such as those involving inadequate parental care and contact (Zucker and Gomberg, 1986) and personality characteristics involving lack of interpersonal connectedness and anxiety proneness as likely antecedents of alcohol abuse (Tarter, 1988). However, as both P.E. Nathan (1988) and R.E. Tarter (1988) recently argued, single variables are less likely to account adequately for the development of alcohol-related problems and alcoholism than more complex models specifying multiple etiologic determinants and interactive effects. Thus, as Tarter (1988) put it, "at each phase of the developmental process, the environment to which the person is exposed exerts a risk-enhancing or risk-attenuating effect on the person" (194). Relative to this perspective, the alternative psychosocial etiologic approach for understanding physician drinking behavior has focused on the nature of medical training and practice. Systematic empirical research from this perspective is quite limited. R. Gardner, S.C. Wilsnack, and H.B. Slotnick (1983) found that the level of social supports experienced by medical students was inversely related to the level of alcohol consumption. Although medical school stressors (such as perceived threats, mastering knowledge, anonymity, peer competition, and long hours) have been shown to predict anxiety (Vitaliano et al., 1984),

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their effect on alcohol consumption has not received similar attention. However, alcohol consumption has been shown to be one form of coping behavior used by individuals in the general population for dealing with stressors (Neff and Husaini, 1982). The profession of medicine encompasses a particular set of stressors as well as a structurally induced lifestyle that impacts on the availability and utilization of social support networks. The salient dimensions of physicians' work experiences likely to impact on their alcohol consumption are reflected in the nature of medical and residency training as well as later medical practice. The clinical years of medical training and the residency period are of particular importance in their roles of socializing future doctors into overall lifestyle patterns as well as imparting particular technical skills. Work-engendered stress begins with the heavy time-related demands of medical and residency training. One of the most common and significant consequences of overwhelming time demands is sleep deprivation, which affects cognitive performance (Friedman, Kornfeld, and Bigger, 1973). In addition to depriving students of sleep, the heavy work load reduces the time available to spend with potentially supportive individuals and organizations and limits leisure time and the range of anxiety-reducing activities (often to those most readily available such as alcohol and drugs) which produces the overwork syndrome (Rhoades, 1973). Beyond the chronic work strains of medical and residency training (likely to function at least in part as a socializing model for future work practices), the diminishing status of medicine in the larger society and its concrete manifestations such as the rising threat of malpractice lawsuits have been shown to adversely affect physicians' psychological well-being (Charles, Wilbert, and Kennedy, 1984). In his classic essay "Social Structure and Anomie," Robert Merton (1968) postulated that deviant adaptations, including alcoholism and drug abuse, are a product of a dysjunction between cultural goals and the existing institutionalized means to achieve them. Merton's primary focus (and the inspiration of a generation of research studies) was on the lack of integration between American values highlighting individual achievement (particularly economic success) and the existing educational and occupational opportunity structure for lower status members of society. Although physicians have achieved a high material standard of living, the social esteem and structural autonomy of medicine have undergone a decline. One example involves the increasing for-profit corporate takeover of American medicine, and the resulting decrease in physician professional autonomy and control over medical decision-making and treatment. This is evidenced, for example, in the creation of standardized quotas regarding the length of patient hospital stays or the number or type of technological procedures which may be ordered (McKinlay and Arches, 1985). From a Mertonian perspective, a major dysjunction for doctors would seem to lie in the discrepancy between societal expectations for medicine and the contemporary structural organization of medical practice.

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Given the high work demands of medicine coupled with the societal ambivalence toward and organizational changes affecting current medical practice, the availability of supportive social relationships to help physicians buffer these stressors and maintain self-esteem becomes extremely important. Yet, a central characteristic of physicians' lifestyles involves the relatively weak level of support from the beginning of medical school training through the residency and into medical practice. Research has shown, for example, that interns in training expect to receive much more support from residents than time permits (Adler, Werner, and Korsch, 1980). In addition, the most significant social support for many individuals in contemporary society—the marital relationship—has not been well integrated with the structure of medical practice (Bates and Carroll, 1975). Divorce and separation among physicians is not significantly higher than that of the general population (Rose and Roscow, 1983); however, 64 percent of residents in one study reported moderate to severe marital conflicts during their first year of residency (Ford, 1983). In sum, a major question for understanding the psychosocial etiology of physician drinking over time involves the relative variance explained by earlier familial experiences and psychologically based vulnerabilities which future physicians bring with them into training for their chosen career versus the stressors and limitations in social supports inherent in the structural characteristics of medical training and later practice.

STUDY DESIGN We began our ongoing study of future physicians during the fall of 1987 by conducting the time 1 survey of the entering class of medical students at a state college of medicine. The time 1 period was intended to tap the premedical school training sources of strengths and vulnerabilities that future physicians bring with them to the initial training environment. Our time 1 questionnaire included measures of early familial disruptions; the quality of earlier parent-child relationships; various personality characteristics including locus of control, interpersonal dependency, masculinity-femininity, and self esteem; symptomatic distress involving anxiety and depression; social supports; recent stressful life events; reasons for drinking reflecting sociability versus escape; and various dimensions of drinking behaviors and alcohol-related problems. The medical student cohort was again surveyed with similar instruments during the fall of their second year of training and will be surveyed again during their third training year in the midst of clinical rotations. An instrument tapping medical school stressors is included in the time 2 and time 3 questionnaires. A major focus of our data analysis entails, first, examining changes in drinking patterns over time. Second, we will test and refine a model delineating changes in drinking and problem-related drinking reflecting the interactive effects of the strengths and vulnerabilities which future physicians bring to the training en-

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vironment and the experiences of medical school-related stressors and the availability or unavailability of social supports during medical training. Our earlier research on medical student cohorts raised some intriguing questions which we are addressing in the current study. First, in a study of gender differences in frequency and quantity of drinking among medical students at entrance to medical school, we found that heavier alcohol consumption patterns among males were associated (though not significantly) with psychosocial "pathology" or dysfunctioning (such as depressive symptomatology, lower social supports, and more ambivalently perceived earlier parent-child relationships). In contrast, heavier consumption patterns among women were significantly correlated with "positive" psychosocial phenomena (low depressive symptomatology, high social supports, and warm, noncontrolling perceived earlier parentchild relations) (Richman and Flaherty, 1986). We speculated that at the start of medical school, drinking by future female physicians may constitute a symbolic social activity signifying the overall successful adoption of previously male social roles. In contrast, male heavier drinking may be more likely to be engaged in as a coping mechanism to deal with stress, depressive mood, and disappointments in earlier and current social relationships. However, given the (hypothesized) more stressful and less supportive nature of medical training and practice for females, we predicted that female drinking will take on a very different (e.g., more pathological) meaning during the training and practice years. In another study of a medical student cohort surveyed at medical school entrance and at the end of the first year of training (Richman and Flaherty, 1988), we found that levels of alcohol consumption and depressive symptomatology significantly increased in male students, while depression and anxiety but not drinking increased in female students. Moreover, both earlier familial experiences as reported at medical school entrance and perceived medical school stressors were predictive of increased subjective distress in both sexes. However, none of our psychosocial variables accounted for the increased drinking by males. We hypothesized that the major effects of both earlier vulnerabilities and medical school environmental conditions on drinking patterns and problems would be manifested somewhat later, after the beginning of the third year of training (which constitutes the beginning of clinical training and the heart of physician academic and lifestyle socialization). Our current study will empirically test these hypotheses. IMPLICATIONS FOR PREVENTION/INTERVENTION STRATEGIES The psychosocial research framework presented here suggests that both the social characteristics of training and work setting environments and the individual psychological attributes and earlier experiences, which workers bring to these settings, may jointly impact on drinking over training and work careers. Research on the relative salience of these different factors as well as their potential inter-

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active effects has major significance for the design and evaluation of interventions in workplace settings. A central question involves the extent to which intervention strategies are most usefully focused on treating individual drinking problems based on assumptions of previously acquired biological or psychological vulnerabilities. Or, alternatively, to what extent are interventions which focus on restructuring pathological characteristics of work settings more efficacious for the treatment and prevention of alcohol-related problems? From an epidemiologic perspective, future cohort studies which are longitudinal and multidisciplinary in design should follow workers in a variety of occupations from the prework or pretraining period through various subsequent points in their training and work careers. The goal of these studies would be to delineate both the alcohol-related vulnerabilities that workers bring with them to different occupations and the ways in which occupational characteristics impact on drinking styles and drinking-related problems. However, as D. Simon (1986) suggested in his analysis of alienation in the workplace and alcohol abuse, epidemiologic researchers have tended to devote primary attention to the study of individual-level factors to the neglect of situational and organizational variables. Intervention researchers may be able to contribute more sophisticated frameworks for addressing the contribution of organizational-level variables to the etiology and course of drinking-related problems. However, the implications of research derived from such frameworks might be to alter organizational dynamics rather than primarily to channel alcoholic individuals into treatment programs. The relative salience accorded to individual vulnerabilities versus work-setting stressors in the design of intervention strategies for dealing with alcohol-related problems should first reflect scientific knowledge derived from well-designed epidemiologic studies. However, the design and application of scientific research occurs within a political context. N. Davis (1975) most clearly addressed the political underpinnings of alternative approaches to understanding deviant behavior. She quoted Thomas Szasz (1970) in regard to the study of slavery: Suppose that a person wished to study slavery. How would he go about doing so? First, he might study slaves. He would then find that such persons are generally brutish, poor and uneducated, and he might conclude that slavery is their 4'natural'' or appropriate social status, (p. 123) Another student, "biased" by contempt for the institution of slavery, might proceed differently. He would maintain that there can be no slave without a master holding him in bondage, and he would accordingly consider slavery a type of human relationship and more generally, a social institution, (p. 124) Both these approaches to understanding slavery may be applied to understanding and intervening in the processes impacting on the development of alcohol problems in the workplace. Yet, there will most likely be an "elective affinity"

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between choice of approach and sociopolitical values regarding the organization of work in contemporary society. CONCLUSIONS: CONCRETE INTERVENTION STRATEGIES From a programmatic perspective, alcohol treatment in the workplace setting should broaden its focus to address the structural dimensions of work environments in addition to treating the psychological vulnerabilities and drinking behaviors of individual workers. In particular, work-engendered stressors should be identified and examined to delineate potential organizational changes. These changes would be designed to decrease the workplace stressors that negatively affect workers and to some extent create the needs for deleterious stress-reducing behaviors such as heavy drinking. In addition, to the extent that social support has been shown to mitigate stress and to relate inversely to drinking, potentially supportive group structures in the work setting should be created or enhanced. Relative to the focus here on the profession of medicine, specific programs and organizational changes characterizing medical school and residency training in some places provide illustrations of environmental-level changes which may decrease drinking in the workplace setting. Within the residency training context, a central source of stress has involved the experience of chronic sleep deprivation linked to the overwhelming work hours demanded of residents. In New York State, proposals were recently formulated which involved the setting of limitations on the hours per week residents are required to work. In the area of enhancing social supports, various medical schools have aided students in forming various types of support groups such as those for female and minority medical students who may share particular stressful experiences linked to the process of becoming physicians. In summary, alcohol treatment programs in varying occupational settings should devote attention to potential ways of altering the organization of work to decrease or minimize stress and to increase sources of interpersonal support. Evaluation research can then be designed to address empirically the extent to which organizational changes are linked with changes in the alcohol-consumption patterns of workers. NOTE The preparation of this paper was supported by Grant Nos. R29AA07311-01 and 02 from the National Institute on Alcohol Abuse and Alcoholism. Joseph A. Flaherty, M.D., is the coinvestigator on this grant.

REFERENCES Adler, R., Werner, E., and Korsch, B. (1980). Systematic study of four years of internship. Pediatrics, 66, 1000-1008.

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Bates, E.M., and Carroll, P. (1975, November). The married intern: Vintage 1983. The Medical Journal of Australia (pp. 763-765). Bissell, L., and Jones, R.N. (1976). The alcoholic physician: A survey. American Journal of Psychiatry, 133, 1142-1146. Brown, G.W., and Harris, T. (1978). Social origins of depression. London: Tavistock. Charles, S.C, Wilbert, R.J., and Kennedy, E.C. (1984). Physician's self-reports of reactions to malpractice litigation. American Journal of Psychiatry, 141, 563565. Clark, D.C., Eckenfels, E.J., Dougherty, S.R., and Fawcett, J. (1987). Alcohol use patterns through medical school. Journal of the American Medical Association, 257, 2921-2926. Coste, C. (1978). The risky business of becoming a doctor. The New Physician, 27, 2831. Davis, N. (1975). Sociological constructions of deviance. Dubuque, IA: Wm. C. Brown. Dohrenwend, B.S., and Dohrenwend, B.P. (1981). Stressful life events and their contexts. New York: Academic Press. Flaherty, J., and Richman, J. (1986). Physician malaise: The discovery and social etiology of psychiatric impairment among doctors. International Journal of Social Psychiatry, 32, 31-37. Ford, C.V. (1983). Emotional distress in internship and residency. Psychiatric Medicine, 1 (2), 143-150. Friedman, R.C., Kornfeld, D.S., and Bigger. T. (1973). Psychological problems associated with sleep deprivation in interns. Journal of Medical Education, 48, 436441. Gardner, R., Wilsnack, S . C and Slotnick, H.B. (1983). Communication, social support and alcohol use in first year medical students. Journal of Studies on Alcohol, 44, 186-193. Johnson, R.P., and Connelly, J.C. (1981). Addicted physicians. Journal of the American Medical Association, 245, 253-257. McKinlay, J.B., and Arches, J. (1985). Toward the proletarianization of physicians. International Journal of Health Services, 15. 161 -194. Merton, R.K. (1968). Social structure and anomie. In R.K. Merton (Ed.), Social theory and social structure. New York: The Free Press. Nathan, P.E. (1988). The addictive personality is the behavior of the addict. Journal of Consulting and Clinical Psychology, 56, 183-188. Neff, J.A., and Husaini, B.A. (1982). Life events, drinking patterns and depressive symptomatology. Journal of Studies on Alcohol, 43, 301-318. Niven, R.G. (1984). Alcoholism in physicians. Mayo Clinic Proceedings, 59, 12-16. Parker, D.A., and Farmer, G.C. (1988). The epidemiology of alcohol abuse among employed men and women In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 113-130). New York: Plenum Press. Pfifferling, J. (1981). The prevention of physical impairment. Journal of the Florida Medical Association, 268-274. Rhoades, J.M. (1973). Overwork. Journal of the American Medical Association, 237, 2615-2618. Richman, J.A., and Flaherty, J.A. (1986). Sex differences in drinking among medical students: Patterns and psychosocial correlates. Journal of Studies on Alcohol, 47, 283-289.

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Richman, J.A., and Flaherty. J.A. (1988, August). Gender differences in medical student distress: Contributions of prior socialization and current role-related stress. Paper presented at the American Sociological Association Annual Meeting, August 1988 in Atlanta, GA. Roman, P.M., and Trice, H.M. (1970). The development of deviant drinking behavior. Archives of Environmental Health, 20. 4 2 4 - 4 3 5 . Rose, K.D., and Roscow, I. (1983). Marital stability among physicians. California Medicine. 116, 9 5 - 9 9 . Scheiber, S . C , and Doyle, B.B. (1983). The impaired physician. New York: Plenum Press. Simon, D. (1986). Alienation and alcohol abuse: The untested dimensions. Journal of Drug Issues, 16 (3), 339-356. Straus, R. (1976). Problem drinking in the perspective of social change: 1940-1973. In W. Filstead, J. Rossi, and M. Keller (Eds.). Alcohol and alcohol problems (pp. 29-56). Cambridge. MA: Ballinger Press. Susser. M., Hopper. K., and Richman. J.A. (1983). Society, culture and health. In D. Mechanic (Ed.). Handbook of health, health care and the health professions. New York: The Free Press. Szasz, T.S. (1970). The manufacture of madness. New York: Harper and Row. Talbott, G.D., and Benson. E.B. (1980). Impaired physicians: The dilemma of identification. Postgraduate Medicine, 68, 5 6 - 6 4 . Tarter, R.E. (1988). Are there inherited behavioral traits that predispose to substance abuse? Journal of Consulting and Clinical Psychology, 56, 189-196. Thomas, C.B., and Duszynski, K.R. (1974). Closeness to parents and family constellation in a prospective study of live disease states. Johns Hopkins Medical Journal, 134, 251-270. Thomas. C.V., Santora, P.B.. and Shaffer. J.W. (1980). Health of physicians in midlife in relation to use of alcohol. Johns Hopkins Medical Journal, 146, 1-10. Vaillant. G.E., Sobowale. N . C . . and McArthur. C. (1972). Some psychological vulnerabilities of physicians. New England Journal of Medicine, 287, 372-375. Vitaliano, P.P.. Russo, J., Carr, J.E.. and Hcerwagen. J.H. (1984). Medical school pressures and their relationship to anxiety. Journal of Nervous and Mental Disease, 172, 730-736. Zucker, R.A., and Gomberg, E.S.L. (1986). Etiology of alcoholism reconsidered: The case of a biopsychosocial process. American Psychologist, 41, 7 8 3 - 7 9 3 .

6 OCCUPATIONAL DRINKING SUBCULTURES: AN EXPLORATORY EPIDEMIOLOGICAL STUDY KAYE MIDDLETON FILLMORE

With the exception of mortality studies, there are at least three major strategies to gain epidemiological information on the relationship between workplace factors and drinking patterns and problems. These strategies may be characterized, in part, as contributing to the differences in orientation of those researchers who have traditionally focused on intervention related models versus those who have traditionally focused on prevention related models in the workplace literature. The first strategy makes use of clinical or incarcerated populations in which proportions of samples employed (vs. unemployed) and/or proportions represented in certain occupational categories are reported (e.g., the classic 1951 study by R. Straus and S.D. Bacon). This epidemiological strategy has been closely identified with those relying on intervention related models by providing justification for case finding within American business and industry. However, these data do little to explicate the relationships between workplace factors and drinking because of major sampling problems—that is, the sample of institutions may be biased with regard to percentages of clientele employed and from given social strata. The second approach consists of studies of specific occupations or industries; such studies rely on a number of different methodologies ranging from interviews within occupational categories (e.g., Manley, McNichols, and Stahl, 1979) to assessments of records within particular industries (e.g., O'Brian, 1949). These studies are less identified with one or the other models. Nonetheless, taken together, they tend to suggest that alcohol problems within the American businesses and industries sampled are concentrated among lower status workers although the degree to which the findings can be generalized is limited. The third includes studies of the general population; these typically are identified with those who advocate prevention models. However, these strategies

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have only rarely been utilized to address the relationship of worksite factors with drinking patterns and problems. This is unfortunate because such studies constitute the only way to (1) compare untreated alcohol problems or rates of alcohol problems/drinking patterns across employment categories or specific industries and (2) determine the relative prevalence and incidence of a variety of alcoholrelated problems and an array of drinking patterns within and across occupations and occupational settings. Within the general population strategy, at least three subtypes are applicable to a workplace alcohol research agenda: (1) studies that examine the drinking patterns and problems within specific occupations (e.g., Hitz, 1973), (2) studies that examine drinking patterns and problems by combining specific occupations usually on the basis of similarity of social class (e.g., Cahalan, 1970), and (3) studies that measure the characteristics of occupations (e.g., job competition and time pressure) with regard to drinking patterns and problems (e.g., Parker and Farmer, 1988). We have said elsewhere (Fillmore and Caetano, 1982) that each of the general population strategies has major problems. Specific occupation studies require extremely large samples to cover adequately even the most common occupations. Studies that combine similar occupations suffer from the fact that they reflect status and income patterns, as well as occupational factors. Studies that measure characteristics of occupations tend to be so abstract and unevocative that it is difficult to generalize them to the occupational structure. In sum, the epidemiological evidence regarding the relationships of drinking to the workplace is poor, regardless of methodological strategy. Apart from differences in the use of epidemiology in the workplace literature that tend to characterize those pursuing intervention versus prevention models is the matter of the research questions addressed by these two camps. Broadly speaking, intervention researchers focus on an epidemiology that seeks to determine the numbers of alcoholics in the workplace with further research efforts designed to evaluate methods of case finding and successes of interventions; prevention researchers focus on an epidemiology that describes an array of drinking patterns and problems in the workplace with further research efforts designed to evaluate structural factors in the workplace that may be reshaped to prevent drinking patterns considered to be contrary to the objectives of the work or to the safety of the employees. To date, these foci have been regarded as incompatible and, to a certain extent, they are. This is due to differential assumptions regarding the nature of the problem per se, the attention paid to disease models, and the emphasis on strategies to curb the problem. Integration of research activities from an epidemiological perspective should not necessarily, in my opinion, involve theoretical compromise for either camp, but there may be integrative mechanisms that will be valuable to both. A quite simple effort would involve measurement. Epidemiological efforts in, say, the prevention camp could integrate operational definitions from the intervention camp into their designs in addition to those normally utilized. And, of

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course, the intervention camp could do the same. This would conceivably serve two purposes: 1. It would yield a greater variety of information which would serve both camps. For instance, in studies performed by interventionists on those identified with alcohol problems within the workplace, a description of drinking patterns, demographics, and conditions of identification would serve the interests of preventionists by locating the types of drinking patterns in given strata of the organization and the mechanisms of identification. This nexus of information would inform the preventionists insofar as knowledge gains regarding occupational tolerance for given types of drinking problems in given strata under given conditions. 2. It would provide, in some cases, a means of testing alternative hypotheses. For instance, in studies on occupational accidents, preventionists could use state-of-the art definitions of alcoholism as well as measures of consumption. The alternative hypotheses would be: Do alcoholics account for greater proportions of accidents or do critical blood alcohol content (BAC) levels of persons not necessarily identified as alcoholics account for the greater proportion of accidents? Should the latter be the case, intervention strategies which are not essentially geared toward disease models may be appropriate. There is a clear need in both camps to use the data at hand more creatively. This chapter is a modest, but rare, attempt to make use of the abundant existing general population data to explicate the relationships between workplace factors and drinking within occupational groups. It may have implications for both camps in its descriptions of naturally occurring factors in occupations and occupational drinking subcultures which, themselves, may initiate or curb drinking styles. INTRODUCTION TO THE ANALYSIS Occupational factors are rarely used to explain drinking patterns. This is surprising in view of the fact that waking hours for the great majority of adults are dominated by time spent at work. When occupation is considered in explanations of drinking patterns, it is most often subsumed under the rubric of social class where occupational types are collapsed with regard to roughly similar educational attainment, income, and occupational prestige. In the small literature in which occupational factors are specifically considered as explanations of drinking patterns, drinking differences across occupations are hypothesized to be related to disjunctions between the person and the job (e.g., job stress and job alienation), to self-selection (e.g., certain types of drinkers are attracted to certain occupations), or to the lack of surveillance on the job (e.g., social controls are minimal and drinking can take place) (see Cosper, 1979, for an overview and critical review of these hypotheses). Furthermore, the research dealing with occupations in the alcohol field is dominated by the emphasis on explaining alcoholism with the underlying logic that workplace factors may facilitate alcoholism and that case finding of alcoholics in the work-

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place is a valued endeavor (see Fillmore and Caetano, 1982, and Fillmore, 1984, for reviews of the occupational alcoholism social movement). The approach in this chapter differs from much of the research in this area. It explores the relationships between the nature of work and the nature of leisure for occupations within different social strata (i.e., social classes) using general population data. It argues that elements of given occupations are directly related to the existence of occupational subcultures. In turn, some of these elements are directly relevant to the existence of occupational drinking subcultures and, subsequently, styles of drinking. Last, it argues that, for some occupations, occupational subcultures and occupational drinking subcultures are critical 4 'intervening variables" standing between factors in the workplace, which are related to leisure time activities (drinking included), and the overall frequency of drinking among the members of that occupation. The exploratory research developed here follows that developed in sociology (Lipset, Trow, and Coleman, 1956; Gerstl, 1961, 1963) that suggests that occupational membership is critical to understanding leisure time activities in general. Furthermore, an understanding of the implications of membership in an occupational drinking subculture would aid in understanding the differences in drinking lifestyles (Cosper, 1979). One rationale for an investigation of occupational membership and leisure time activities and the degree to which alcohol use is embedded in these domains is that it provides an alternative perspective to workplace factor theories which are almost solely based on individualistic explanations. To assess effectively differential occupational factors as they relate to occupational subcultures and drinking subcultures, it is necessary to hold social class constant. A contrast across occupations without regard to social class might describe differences in social strata but would obscure the relationship between the structure of the occupation and behavior. THE WORKPLACE FACTORS AND THE HYPOTHESES Six occupations within three social strata are compared on the basis of three workplace factors—factors on which the exploratory hypotheses will be based. Table 6-1 summarizes the occupations and factors under consideration. Many of the hypothesized occupational differences in Table 6-1 come to us from common knowledge in the culture (e.g., technicians are normally confined to the workplace and sales representatives are on the road; the relative availability of alcohol on the job is higher with food handlers working in restaurants and bars than with truck drivers). The exploratory hypotheses derived from these differences are used to predict the existence of occupational subcultures and, in some cases, the existence of occupational drinking subcultures. The general hypotheses are as follows (specific hypotheses for each strata and rationale for them may be found in the text that follows):

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Table 6-1 Occupations within Social Strata by Workplace Factors Hypothesized to Differentiate between Them Occupational Factors Co--worker teamwork

Accessibility to CO--workers

Occupations within social strata Group 1: Technicians Sales Reps Group 2: Recording Clerks Protective Service Workers Group 3: Food Handlers Truck Drivers

High Low

On-the-job alcohol availability

Low High

Low

High

Low

High

Low

High

High Low

High Low

1. Hypotheses regarding accessibility to co-workers: (a) occupations characterized as

having relatively higher accessibility to co-workers (e.g., day-to-day interaction) will be more likely to form occupational subcultures than those with relatively lower accessibility; (b) higher accessibility occupations will have a higher probability of forming drinking subcultures. 2. Hypothesis regarding teamwork: occupations rated as requiring relatively more team-

work among those in the same occupational category will be highly likely to form occupational subcultures and drinking subcultures. The teamwork factor will be a more powerful predictor than accessibility (i.e., it will predict formation of occupational subcultures and drinking subcultures regardless of the relative degree of accessibility of co-workers). 3. Hypothesis regarding on-the-job alcohol availability: relative on-the-job alcohol avail-

ability will be related to positive attitudes of permissiveness in drinking with colleagues at lunch and in drinking on the job.

METHOD The Sample The sample from which the data for this chapter were drawn comes from a 1984 survey of the U.S. general population (n = 5,178; 2,081 men) (Hilton and Clark, 1987). In this survey blacks and Hispanics were oversampled, thus weights (based on race, age, sex, and region) are used in reporting results. The sample used in this chapter consists of selected occupations (males only) from the larger sample where the sample sizes (unweighted) within the occupations were considered adequate for analysis. Because blacks and Hispanics were oversampled and because these groups tend to occupy jobs in the lower

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social strata of the society, the sample as a whole was skewed toward these occupations. Occupations with roughly the same educational achievement and family income are regarded to be of similar social strata. However, since there is some variation within occupations on both these factors, the analyses control for income and education as well as other variables.

Some Assumptions and the Analysis Plan In much of the general population research, it is a tacit assumption that, if a person is identified with a demographic label (e.g., age, sex, social class, or race), he or she is somehow connected to others holding the same label. This research utilizes this assumption by examining (1) the degree to which the occupational label implies an occupational subculture (Lipset, Trow, and Coleman, 1956) with activities taking place both inside and outside the workplace, (2) the degree to which the occupational label implies an occupational drinking subculture outside the workplace, (3) the degree to which occupations may be characterized by their drinking attitudes and their relationship to socializing with and drinking with co-workers, and (4) the degree to which socializing with members of the occupational subculture and drinking with members of the occupational subculture account for the total frequency of drinking within each occupational group. Since the sample is that of a national general population, there is no reason to believe that the respondents in a given occupational group are actually in contact with one another. It might be argued, then, that the appropriate methodology for an occupational subculture study would be to sample within geographically limited occupational groups (i.e., sampling truck drivers in one company). It is argued here that if relatively strong relationships are found (e.g., the frequency of socializing with colleagues and the frequency of going to bars) among members of a geographically dispersed occupational group, then the relationships would potentially be stronger if the data were collected in a more limited geographical area. Research on occupational factors is burdened by the fact that many occupations are characterized by other demographic factors (e.g., age, education, and marital status) which, in turn, are related to drinking practices. Research on leisure time activities is burdened by the fact that participation in these activities is also characterized by other demographic factors. Therefore, to control for these effects, partial correlations are presented, after removing the effects of age, marital status, income, and education. A major limitation of the analysis is that it is purely associational, precluding the specification of casual linkages between the variables measured.

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The Variables Co-worker socializing is assessed by the question, "Please think about the people you have met at work or through (your husband's/your wife's/your living mate's) work. How often do you get together with people you have met through work?" (fairly often, once in a while, never). Co-worker drinking is assessed by the question, "When you get together socially with people from work, how often are drinks containing alcohol served?" (nearly every time, more than half the time, less than half the time, once in a while, never). Frequency of drinking is assessed by a scale which ranges from never to three or more times per day. Number of times drunk in the past year is assessed by a numerical count. Social context data were gathered on the frequency of going out for an evening meal in a restaurant, not including fast-food places and luncheonettes (never, sometimes but less than once a month, one to two times a month, three to four times a month, once a week or more); going to bars, taverns, or cocktail lounges; going to parties at someone else's home; having friends drop over and visit in your house; and hanging around with friends in a public place, such as a park, street, or parking lot. Drinking attitude data were gathered from reactions to such statements as "getting drunk is just an innocent way of having fun" (agree, disagree); "having a drink is one of the pleasures in life"; "people drink on the job where I work"; and "a real man can hold his liquor." RESULTS Technicians and Sales Representatives Hypothesis 1: Occupations with greater day-to-day contact are more likely to form occupational subcultures than those with less day-to-day contact. The work of technicians may be characterized as that which is confined to the workplace with little client contact. On the other hand, the work of sales representatives (sales reps) may be characterized as that which is on the road with considerable client contact and, as popular notions inform us, frequent entertainment of clients including drinking.

Sales reps are less likely to socialize with co-workers than are technicians which, in general, confirms our hypothesis (Table 6-2). Sales reps are more likely to go out to restaurants, to lunch, and to parties; technicians are slightly more likely to hang out in public. The correlational data indicate that the coworker socializing among technicians is more strongly related to the frequency of going to bars, restaurants, parties, and having friends drop in than it is among sales reps. Together, these data suggest a stronger occupational subculture among technicians than among sales reps.

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Table 6 - 2 Frequency of Drinking and Drunkenness, Socializing with Colleagues, Drinking with Colleagues (among those who socialize), Leisure Time Activities, and Attitudes toward Drinking for Technicians and Sales Representatives*

Frequency of drinking Abstainers 3 times a month or less 1-2 times per week 3-4 times per week Nearly every day or more

Technicians (30)

Sales Reps (39)

0 24 27 19 30

0 34 24 16 25

Number of times drunk in last year Never 1-6 times 7 or more times

53 23 24

41 33 26

Frequency of socializing with co-workers Never Once in a while Fairly often

29 50 21

47 25 28

Almost always drinks when socializing with co-workers

44

45

Leisure time activities Goes to bars one a week + Goes out to lunch once a week + Goes to restaurants once a week + Goes to parties once a month + Quiet evening homes less than once a week Friends drop in weekly + Hangs out in public once a month +

22 15 48 25 11 22 13

18 38 90 44 8 25 6

O.K. to drink at work O.K. to drink with co-workers at lunch People drink on the job where I work Getting drunk is just an innocent way of having fun A real man can hold his liquor Having a drink is one of the pleasures in life

7 41 38

10 43 31

10 4

12 15

77

54

I would prefer another occupation

35

18

•Percentages are weighted Hypothesis 2: Due to the relative lack of co-worker accessibility among sales reps, there will be a much lower probability of an occupational drinking subculture forming in this group as compared to technicians. Among those who do drink with their co-workers, the association of drinking with co-workers and frequenting a wide variety of social contexts should be higher among technicians compared to sales reps.

Although there are no major differences in drinking frequency per se between the two groups (Table 6-2), it is clear that technicians who socialize with coworkers are highly likely to drink with them, but correlational data indicate that socializing with colleagues is only moderately related to the total frequency of drinking in this occupational group. Socializing with colleagues is negatively related to the total frequency of drinking among sales reps. These findings further

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confirm that there is an occupational drinking subculture among technicians but not among sales reps. Correlational analyses make these differences clear if one compares the contexts that are most associated with the total frequency of drinking to those most associated with the frequency of drinking with co-workers. The association between co-worker drinking and the frequency of drinking in bars and restaurants and at parties is strong and significant for technicians, but going to parties and out to lunch are those variables most strongly associated with frequency of drinking per se. This suggests that, although the frequency of technicians' drinking is not totally confined to the presence of co-workers, parties where co-workers are most probably present account for much of the drinking in this group. On the other hand, there are no significant relationships among the context variables and the frequency of drinking with work colleagues among sales reps. Rather, the frequency of drinking in this group is accounted for by lunches and restaurants when co-workers are not present (and clients most probably are) and when friends drop in. Thus, the drinking worlds of technicians and sales reps are quite different. The difference, according to our hypothesis, is at least partially due to the accessibility of co-workers. Hypothesis 3: Because the availability of alcohol on the job is thought to be higher among sales reps (by virtue of the fact that entertaining of clients may include drinking), sales reps will be more likely to approve of drinking at lunch and on the job and to regard it as one of the pleasures in life. Given the hypothesized integration of drinking with work activities, it is expected that sales reps will be more likely to report that kka real man can hold his liquor," which would deny alcohol's interference with work goals. Sales reps and technicians are equally likely to approve of drinking with colleagues at lunch and on the job (Table 6-2). However, correlational data reveal that, although the association of socializing with co-workers is negatively related to approval of drinking during work hours for both groups, the relationship between drinking with colleagues and approval of drinking during work hours is positive for sales reps and negative for technicians. These findings suggest that, to the extent that drinking subcultures exist among sales reps, on-the-job drinking is condoned, whereas it is not among technicians. The approval of drinking at lunch is associated with socializing with colleagues among sales reps but not among technicians, suggesting an occupational social norm among technicians that does not condone lunchtime drinking; however, the relationship of this variable with drinking with co-workers among technicians is positively related, and it is negatively related to the frequency of drinking. This suggests that, to the extent to which there is an occupational drinking subculture among technicians, the approval of drinking at lunch accounts for little of the overall drinking frequency. Technicians are much more likely to perceive drinking as one of the pleasures of life, while sales reps are more likely to think that a real man can hold his

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liquor (Table 6-2). These attitudes may be central to the meaning of drink between these groups. From correlational analyses, it is clear that sales reps, especially those who drink more frequently, are more likely to regard drink as one of the pleasures in life. The minority of those sales representatives who do socialize with their colleagues do not. This suggests that the isolation of sales reps from their occupational peers and the integration of drinking with business may promote the maximization of drinking as a central pleasurable feature in life. Even technicians' frequency of drinking is only moderately associated with this value, suggesting that association with occupational peers and the lack of drinking as a part of business put drink in a secondary relationship to socializing per se. In sum, this series has suggested that the notion of co-worker accessibility has implications for the emergence of occupational drinking subcultures and that the meanings and contexts of drinking may be linked to the nature and degree to which alcohol is a part of the occupation itself. Recording Clerks and Protective Service Workers Hypothesis 1: The impact of co-worker accessibility on the formation of occupational subcultures will be reduced when the necessity for co-worker teamwork is high. In this series, accessibility to co-workers is high among recording clerks (clerks) but teamwork is low. In contrast, accessibility to co-workers is low among protective service workers (PSW) but teamwork is high. Specifically, it is hypothesized that clerks will socialize with co-workers more frequently because of higher day-to-day co-worker accessibility. When co-worker socializing does take place among PSW. it will show a stronger relationship to a wider variety of social contexts as a result of the mutual dependence implied by teamwork responsibilities. As predicted, clerks socialize with co-workers more frequently than do PSW (Table 6-3). PSW are more likely to go to bars and out to lunch and are less likely to spend a quiet evening at home; clerks are more likely to go to restaurants and parties and to hang out in public places. The correlation of socializing with colleagues is strong for both groups with the frequency of going out to lunch. The association of socializing with co-workers is somewhat more strongly related among PSW with going to restaurants and parties and is positively related among PSW and negatively related among clerks with going to bars and quiet evenings at home. These findings modestly support the hypothesis that PSW who do socialize with co-workers will do so across a greater range of social contexts. Hypothesis 2: Jobs implying relatively more teamwork will have a higher probability of forming occupational drinking subcultures. Among those who do drink with co-workers, the associations of frequency of co-worker drinking and being in more social contexts should be higher in occupations requiring relatively more teamwork. Furthermore, the overall frequency of drinking with co-workers should be more highly related to the frequency of drinking per se in these occupations.

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Table 6 - 3 Frequency of Drinking and Drunkenness, Socializing with Colleagues, Drinking with Colleagues (among those who socialize), Leisure Time Activities, and Attitudes toward Drinking for Recording Clerks and Protective Service Workers*

Frequency of drinking Abstainers 3 times a month or less 1-2 times per week 3-4 times per week Nearly every day or more

Recording Clerks (24)

Protective Service Workers (40)

20 32 21 17 10

7 53 6 33 1

Number of times drunk in last year Never 1-6 times 7 or more times

6 93 1

31 36 33

Frequency of socializing with co-workers Never Once in a while Fairly often

19 42 39

46 43 10

Almost always drinks when socializing with co-workers

47

50

Leisure time activities Goes to bars one a week + Goes out to lunch once a week + Goes to restaurants once a week + Goes to parties once a month + Quiet evening homes less than once a week Friends drop in weekly + Hangs out in public once a month +

1 1 22 20 10 39 27

15 18 10 5 20 32 2

0 18 50

6 22 15

O.K. to drink at work O.K. to drink with co-workers at lunch People drink on the job where I work Getting drunk is just an innocent way of having fun A real man can hold his liquor Having a drink is one of the pleasures in life

34 5

15 9

21

40

I would prefer another occupation

70

43

'Percentages are weighted

Clerks are more likely to be frequent drinkers and much more likely to get drunk between one and six times a year; PSW are slightly less frequent drinkers and are more likely never to get drunk or more likely to get drunk seven or more times a year (Table 6-3). The frequency of associating with co-workers and drinking with them is highly related among PSW but unrelated among clerks, and the frequency of drinking with co-workers is highly and significantly correlated with the frequency of drinking per se among PSW but not among clerks. These findings strongly suggest that, to the extent to which an occupational subculture exists among PSW, it is an occupational drinking subculture because it accounts for much of the total frequency of drinking.

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The contexts most highly associated with co-worker drinking among PSW are bars and hanging out in public places and among clerks are hanging out in public places, bars, and lunch. Noteworthy is that there is a positive correlation between drinking with co-workers and going out to lunch for clerks and a negative one for PSW; there is a negative association between drinking with co-workers and going to parties among clerks and a positive one for PSW. These findings suggest that co-worker drinking is more likely to centralize around workplace hours for clerks and more likely to extend into leisure time hours for PSW. Those contexts most highly associated with frequency of drinking per se for PSW are bars and parties (both of which were positively associated with frequency of drinking with co-workers). Since the association of drinking in bars and drinking at lunch with the frequency of drinking per se is lower than that with drinking with co-workers among clerks, we reaffirm the notion that this group has a weaker occupational drinking subculture than PSW. Hypothesis 3: Occupations that require teamwork are more likely to hold common attitudes toward drinking, particularly among members of these occupations who drink with coworkers. Furthermore, since teamwork implies camaraderie and belonging, occupations with higher teamwork will be less likely to prefer another occupation. Clerks are more likely to regard getting drunk as an innocent way of having fun; PSW are more likely to regard drinking as one of the pleasures in life (Table 6-3). The impact of the occupational drinking subculture on drinking attitudes may be observed in the item, "a real man can hold his liquor.'' While it is positively correlated with co-worker socializing in both groups, it is significantly and positively related to drinking with co-workers for PSW and negatively related to drinking with co-workers for clerks. To a lesser degree, the attitude that drink is one of the real pleasures in life suggests the stronger commonality of these social norms among PSW who engage in co-worker drinking, but this is most probably influenced by the most frequent drinkers in this group. The great majority of clerks would prefer another occupation, but less than half of the PSW would. While this variable is not associated with either the frequency of socializing with colleagues or drinking with them, it implies a worldview among the PSW which is derived from notions of teamwork and belonging. The notion of teamwork may be implicated in the frequency of getting drunk in the occupational drinking subculture. Although drinking with co-workers is more strongly associated with the frequency of getting drunk among clerks, the correlation is not as strong among PSW. However, the relationship of the frequency of getting drunk and the frequency of drinking per se is stronger among PSW than clerks. This suggests, to a modest degree, that the social norms associated with occupational drinking prevent drunkenness when PSW drink together.

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Hypothesis 4: Because the availability of alcohol on the job is thought to be higher among PSW (by virtue of the fact that there is less supervision in these jobs), PSW will be more likely to approve of drinking at lunch and on the job. On the whole, clerks and PSW do not differ with respect to reporting approval of drinking when out to lunch. However, clerks and PSW differ with respect to the association between socializing with colleagues and the approval of drinking at lunch (positive among clerks and unrelated among PSW), which contradicts the hypothesis. The relationship becomes much stronger among clerks when it is confined to those who drink with their colleagues. This suggests a social norm of condoning drinking at lunch in the weaker occupational drinking subculture of clerks. None of the clerks and only 6 percent of the PSW regard drinking at work with approval. In sum, this series has suggested that the notion of teamwork has implications for the emergence of occupational subcultures, drinking subcultures, and styles of drinking. In addition, the findings suggest that even when alcohol availability is higher in occupations characterized as requiring relatively more teamwork, the social norms of the occupational drinking subculture—contrary to expectations—may prevent on-the-job drinking, lunchtime drinking, or drunkenness in that social context. Food Handlers and Truck Drivers Hypothesis 1: Occupations with higher co-worker accessibility (food handlers) will be more likely to form occupational subcultures than occupations ranked as lower on this variable (truck drivers). As predicted, food handlers (FH) socialize more frequently with co-workers than truck drivers (TD) (Table 6-4). FH are more likely to go to bars and parties; TD are more likely to go out to lunch, hang around in public places and to have friends drop in. Socializing with co-workers is negatively related to the frequency of going to bars but positively related to the frequency of having friends drop in among TD; it is negatively related to the frequency of spending quiet evenings at home among FH. These findings suggest that, to the extent to which occupational subcultures exist in these groups, the socializing is more likely to take place in the home for TD and outside the home for FH. Hypothesis 2: Occupations implying relatively more accessibility to co-workers will have a higher probability of forming occupational drinking subcultures. Among those drinking with co-workers, the association of frequency of drinking with co-workers and drinking in a wide variety of social contexts will be higher in occupations with higher accessibility to co-workers. FH are somewhat more likely to drink more frequently than TD; however, TD are more likely to get drunk, implying less frequent but sporadic heavy

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Table 6-4 Frequency of Drinking and Drunkenness, Socializing with Colleagues, Drinking with Colleagues (among those who socialize), Leisure Time Activities, and Attitudes toward Drinking for Food Handlers and Truck Drivers*

Frequency of drinking Abstainers 3 times a month or less 1-2 times per week 3-4 times per week Nearly every day or more

Food Handlers (31)

Truck Drivers (61)

14 33 14 7 32

13 19 29 16 23

Number of times drunk in last year Never 1-6 times 7 or more times

26 43 31

12 15 73

Frequency of socializing with co-workers Never Once in a while Fairly often

34 56 9

58 30 12

Almost always drinks when socializing with co-workers

50

7

Leisure time activities Goes to bars one a week + Goes out to lunch once a week + Goes to restaurants once a week + Goes to parties once a month + Quiet evening homes less than once a week Friends drop in weekly + Hangs out in public once a month +

31 4 11 35 9 28 14

8 18 8 11 15 34 24

O.K. to drink at work O.K. to drink with co-workers at lunch People drink on the job where I work Getting drunk is just an innocent way of having fun A real man can hold his liquor Having a drink is one of the pleasures in life

0 21 42

9 32 42

19 10

29 25

67

62

I would prefer another occupation

69

61

* Percentages are weighted drinking episodes among this group (Table 6-4). The frequency of socializing with co-workers is positively related to the frequency of drinking with co-workers as well as to the frequency of drinking per se among FH and unrelated among TD. These findings strongly suggest that, to the extent to which an occupational subculture exists among FH, it is an occupational drinking subculture because it accounts for much of the total frequency of drinking, which supports the hypothesis. The contexts most highly associated with co-worker drinking for FH are parties, bars, and having friends drop in. Co-worker drinking for TD is associated with the frequency of going to bars alone. The hypothesis is supported

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with regard to the number of social contexts associated with drinking among occupations with higher co-worker accessibility. The contexts associated with frequency of drinking per se are friends dropping in, parties, lunch, and bars for FH—contexts also associated with co-worker drinking. However, the context most highly associated with frequency of drinking among FH is hanging out in public—a context not associated with co-worker drinking. The context most highly associated with frequency of drinking among TD is the frequency of going to bars. These findings suggest that the majority of the contexts associated with frequency of drinking are those which imply the presence of co-workers for FH but that TD drinking is confined to bars with a somewhat high probability that co-workers will be present. Hypothesis 3: Because the availability of alcohol on the job is thought to be relatively higher among food handlers (by virtue of the fact that they work in establishments that often serve alcohol), food handlers will be more likely to approve of drinking on the job and at lunch compared to truck drivers. Given the hypothesized integration of drinking with work activities, it is expected that food handlers will be more likely to report that "a real man can hold his liquor," which would disallow alcohol's interference with work goals. TD are slightly more likely to approve of drinking with colleagues at lunch. This attitude, however, is associated with frequency of drinking per se but not with the existence of an occupational subculture or drinking subculture; it is strongly associated with the occupational drinking subculture among FH. None of the FH report approval of drinking during work hours whereas only 9 percent of TD do; the latter is more related to the frequency of drinking per se than to the indicators of occupational subculture or drinking subculture. In sum, these findings support the hypothesis to the extent that approval of drinking at lunch is associated with the drinking subculture among FH but do not support it with respect to the extent to which there is approval of drinking on the job. TD are also slightly more likely to report that a real man can hold his liquor. This attitude is similarly related to co-worker socializing among the two groups, but it is more strongly related to co-worker drinking and to frequency of drinking per se among FH and negatively related to co-worker drinking and frequency of drinking among TD. These findings would support the hypothesis to the extent that this attitude is manifest in the drinking subcultures of FH. Apart from the hypotheses proposed here, several other findings are worthy of note. TD are slightly more likely to regard getting drunk as an innocent way of having fun. This attitude is more strongly associated with the existence of an occupational subculture per se than with an occupational drinking subculture or the frequency of drinking per se. On the whole, TD and FH are equally likely to prefer another occupation. This preference is strongly related to the frequency of drinking with co-workers among FH, suggesting a drinking subculture organized around occupational discontent in this group.

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In sum, this series has suggested that co-worker accessibility and on-the-job alcohol availability have implications for the formation of occupational and drinking subcultures and for attitudes regarding drinking.

CONCLUSIONS This exploratory study has endeavored to link characteristics of specific occupations within social strata to drinking styles and attitudes by examining the intervening variables of occupational subcultures and occupational drinking subcultures. Briefly, the findings demonstrate that the notion of teamwork may elevate the formation of occupational subcultures and occupational drinking subcultures. This notion also was related to a wider variety of leisure time activities associated with co-worker drinking and attitudes. Taken together, these findings suggest that the notion of occupational identity (through camaraderie or mutual dependence) has implications for leisure time activities and drinking styles and attitudes. When teamwork was not a pertinent differentiating variable, the notion of coworker accessibility had implications for the study variables in the comparisons of technicians versus sales representatives and food handlers versus truck drivers. Co-worker accessibility tends to elevate the formation of occupational subcultures as well as occupational drinking subcultures, certainly to the extent of drinking with co-workers across a wider variety of social contexts. The degree to which alcohol is available in the workplace can be compared among the three groups in two ways. Food handlers (compared to truck drivers) and sales representatives (compared to technicians) are occupations in which alcohol may be more greatly integrated into the day's business. On the other hand, protective service workers (compared to clerks) are more likely to have alcohol available to them as a result of lack of supervision. Indicators of permissive attitudes of job-related drinking (drinking on the job or drinking with co-workers at lunch) were more likely to occur among those working where drinking is integrated into the job. There was an indication that the attitude of a real man can hold his liquor—which we suggested may disallow the notion that use of alcohol interferes with work goals—was associated with occupations where alcohol is a part of business and is expressed either independently or as a part of a drinking subculture. These findings have implications for broader literatures. An important notion in the contemporary alcohol field links the sheer availability of alcohol to per capita consumption and, hence, to alcohol-related problems. The underlying assumption of this notion concerns the nature of man—that is, if alcohol is readily available, it is highly likely to be consumed. The findings here suggest that standing between the sheer availability of alcohol and the consumption of it are a number of social norms (in this case, occupational norms) and social contexts which prevent drunkenness (e.g., the negative relationship between

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drinking with co-workers and drunkenness for those where there is a high availability in the workplace). Much of the occupational alcoholism literature has argued that differences in heavy drinking or alcoholism across occupations arise from disjunctions between the person and the job (e.g., job stress or alienation). We dispute this conclusion if it may be assumed that the preference for one's own occupation may be tentatively regarded as an indirect measure of the degree to which individuals feel stress or alienation in their work. Clearly some occupations may be characterized as having more job dissatisfaction than others (e.g., clerks more than protective service workers). However, the rate of drunkenness does not seem to differ greatly in characterizing these occupations, and often it goes in a direction opposite to this prediction. It has also been argued that heavy drinkers or alcoholics self-select into the occupations that are characterized as more permissive in regard to drinking or as having a higher alcohol availability on the job. If drunkenness may be used as a surrogate variable for heavy drinking, it is noteworthy that sales reps (characterized as less supervised with alcohol available on the job) were equally likely to get drunk as technicians. Protective service workers (characterized as less supervised) were more likely never to get drunk than clerks, although an equal number were more likely to get drunk frequently. Truck drivers (who are less supervised) are highly likely to get drunk on a frequent basis compared to food handlers (who have greater availability of alcohol on the job). Comparison within social strata (which is reasonable given the employment opportunities available to people) suggests that the self-selection hypothesis has been oversimplified. The exploratory findings have implications for both intervention and prevention of an array of drinking patterns. For instance, contingent on occupational category, from 15 to 50 percent of the respondents reported that 4'people drink on the job where I work." This suggests on-site drinking, with and without the support of occupational subcultures, and it should be investigated to facilitate prevention strategies, particularly with regard to alcohol-related accidents. Furthermore, it suggests that occupational subcultures may operate as a source of impeding or promoting alcoholism treatment success. In general the findings have illustrated that, when the highly confounding effects of age, marital status, income, and education are removed, occupational membership has implications for describing leisure time activities in general and drinking contexts and drinking subcultures in particular. These exploratory data suggest that occupational factors hold much promise for understanding the social norms that account for different drinking styles in society.

NOTE This work was supported by a National Institute on Alcohol Abuse and Alcoholism Research Scientist Development Award (1 K02 AA 00073). Appreciation is extended to

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the grantees of the NIAAA Alcohol Research Center Grant at the Alcohol Research Group for use of their national data in these analyses.

REFERENCES Cahalan, D. (1970). Problem drinkers: A national survey. San Francisco: Jossey-Bass. Cosper, R. (1979). Drinking as conformity: A critique of sociological literature on occupational differences in drinking. Journal of Studies on Alcohol, 40, 868-981. Fillmore, K.M. (1984). Research as a handmaiden of policy: An appraisal of estimates of alcoholism and its cost in the workplace. Journal of Public Health Policy, 5, 40-64. Fillmore, K.M., and Caetano, R. (1982). Epidemiology of occupational alcoholism. In Occupational alcoholism: A review of research issues (pp. 21-88). NIAAA Research Monograph No. 8. Washington, DC: U.S. Government Printing Office. Gerstl, J.E. (1961). Determinants of occupational community in high status occupations. The Sociological Quarterly, 2, 37-48. Gerstl, J.E. (1963). Leisure, taste and occupational milieu. In E.O. Smigel (Ed.), Work and leisure: A contemporary social problem. New Haven, CT: College and University Press. Hilton, M.E., and Clark, W.B. (1987). Changes in American drinking patterns and problems, 1967-1984. Journal of Studies on Alcohol, 48, 515-522. Hitz, D. (1973). Drunken sailors and others: Drinking in specific occupations. Quarterly Journal of Studies on Alcohol, 34, 496-505. Lipset, S.M., Trow, M.A., and Coleman. J.S. (1956). Union democracy: The internal politics of the international typographic union. Glencoe, IL: Free Press. Manley, T.R., McNichols, C.W., and Stahl, M.S. (1979, August). Alcoholism and alcohol related problems among U.S.A.F. civilian employees. (AFIT Technical Report 79-4). Wright-Pattison Air Force Base. OH: U.S. Air Force University, Air Force Institute of Technology. O'Brian, C.C. (1949). Alcoholism among disciplinary cases in industry: A preliminary study. Quarterly Journal of Studies on Alcohol, 10, 268-278. Parker, D.A., and Farmer, G.C. (1988). The epidemiology of alcohol abuse among employed men and women. In M. Galanter (Ed.). Recent developments in alcoholism (Vol. 6). New York: Plenum Press. Straus, R., and Bacon, S.D. (1951). Alcoholism and social stability. A study of occupational integration of 2,023 male clinic patients. Quarterly Journal of Studies on Alcohol, 12, 231-260.

7 DRINKING, SOCIAL NETWORKS, AND THE WORKPLACE: RESULTS OF AN ENVIRONMENTALLY FOCUSED STUDY GENEVIEVE AMES AND CRAIG J A N E S

INTRODUCTION Across three centuries of American history there has been a common thread in the belief that problem drinking and alcoholism are related to individual deviance. According to the historians who have studied alcohol issues from the Temperance era to recent times, the source and context of this deviance have varied, ranging from profound moral deficiency, to illegal behavior, to biochemical dysfunctions. Today, the analytic tendency to reduce alcohol problems to some underlying flaw in the individual still continues unabated. This kind of reductionist thinking is not unique to studies of alcohol use or even psychological disorders in general; it reflects a general historical thrust in the health sciences to search out single underlying causes of disease and illness at the level of the organism and thereby to ignore levels of causality which involve the relationship of an individual to his or her natural and social environment (cf. Engel, 1977; Ratcliffeet al., 1984). A review of historical literature on alcohol policy in the workplace from the colonial period to the present thus reveals the perspective that the individual problem drinker has always been and still is viewed as a menace to a productive and profitable workplace, and policies to change, alter, prevent, or treat the problem have been and still are focused primarily on that individual (Ames, 1989). Although some industries have attempted to create a workplace environment that does not encourage drinking, for the most part such movements have occurred regionally or in the occupations in which alcohol-impaired workers expose the employer to liability risk, such as the transportation industry. In general, there has been no widespread movement by American industry to share responsibility for the drinking problems of its workers (Ames, 1989).

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The logical fallacy of such a position is revealed in anecdotal accounts of onthe-job drinking practices from different periods of American history. For example, in the records of the building of a government house in Albany, New York, in 1656, it was written that alcohol was provided by the employer to all of the tradesmen who constructed the public building. Workers not only received alcohol as part of their wages, they also were provided with alcohol on the job and were allowed to drink it openly while working and during breaks and meals. Crews constructed this house in 1656 and the men received drink rations and special allowances at various stages of work. First, the men who demolished the old fort received strong beer. When the first stones of the wall were laid the masons were given brandy. Then the carpenters got two barrels of strong beer, three cases of brandy, and small beer when the cellar beams were laid. The men who carried the beams to the carpenters from outside the fort received one-half barrel of beer for each beam they carried (a total of 16l/2 barrels). The carpenters got two more cases of brandy and a barrel of beer when the second level of beams were laid. The tile setters got a half barrel of "tiles-beer" and the carpenters another half barrel for the roof tree. The completion of the winding staircase called for another treat of liquor for the workmen. Additionally, the carriers, teamsters, carpenters, stone-cutters, and masons received a gill of brandy and three pints of beer a day. The alcohol bill alone amounted to almost 6c/c of the total cost of building this government house. (Earle, 1938, quoted in Staudenmeier. 1985, 19-20) We can assume from historical records such as the above as well as others (Ames, 1989) that employers of earlier days tolerated, in fact, promoted, onthe-job drinking. The accepted principle here is that drinking motivates work and is tied directly to the reward structure. That this is not a quaint example out of history is evident if we look at contemporary examples. In a 1985 study of heavy machinery assembly workers in a major American industry, we found that on-the-job drinking was a daily occurrence, especially when shift and overtime work was concerned. In the words of one worker: We had bottles in our lockers, bottles in the box that we sat on as we waited for the next unit to come down the line, and we'd go out at lunch and drink. We drank after lunch every day . . . everyday. . . . When I had to go on the night shift, it got to the point where booze was the only way to go. I'd go to work sober and come home drunk—1 mean that is if I made it home after work. . . . Because everybody had a drink while they worked. . . . 1 used to drink sitting on my forklift; I'd stop someone and offer him a drink. Somebody else would offer me one later... it was just the accepted thing. (Janes and Ames, 1989) The similarity of workplace drinking patterns in the postrevolutionary period to this example from the present raises the basic question of why on-the-job drinking still occurs in a modern manufacturing plant. Anecdotal data from the earlier periods suggest that drinking was possible in the old days not only because alcohol was provided, but also because it was viewed as a healthful substance

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and a good substitute for tasteless water: daily and frequent consumption of alcoholic beverages was the accepted cultural norm (Levine, 1984). It could also be assumed that the low-technology, slower paced style of work in the old days accommodated drinking. By this logic, and with the fact of today's higher technology, faster pace of work, and general belief that frequent alcohol consumption is not a healthful practice, one would speculate that rampant or even occasional on-the-job drinking would not be possible in a contemporary workplace. However, as shown in the results from our recent study of the above mentioned assembly workers, on-the-job drinking is possible in today's workplace, and clearly, for some workers, is an ongoing practice. In addition to a number of other factors of the work environment that led to workplace drinking, alcohol use in this plant was tacitly approved by lower level management as a way to keep the workers uncomplaining and working. Such attitudes led to a high level of social and physical availability of alcohol on the job. Similar to postcolonial days, workers in the modern assembly plant of 6,000 employees daily entered a work environment wherein drinking was ongoing and implicitly sanctioned by employers. As incredible as it might seem, in both time periods, employer complicity in on-the-job drinking is in evidence (Ames and Janes, 1987). In this chapter, we advocate the need to pay more attention to the extent of on-the-job drinking, the fact that workers with drinking problems are not necessarily alcoholic or deviant in nature, and the growing body of evidence that suggests on-the-job drinking is integrated into the workplace environment. To illustrate the basis for our primarily environmental perspective on explaining workplace-related drinking and drinking problems, we present here a critical summary of the occupational literature that has influenced our thinking, followed by specific data from our findings in a recent study of a population of assembly workers. Following that, it should be clear that rather than focus exclusively on individual attributes of problem drinking, it is necessary to place these attributes firmly in the context of a particular work situation and set of social relationships. It is through this effort that workplace-centered primary prevention strategies and more effective treatment programs are most likely to emerge. A CRITICAL SUMMARY OF RELEVANT LITERATURE Two important points emerge from the research and reports (see Mannello et al., 1979, and Harrington, Mosher, andColman, 1987) on work-related drinking. First, on-the-job drinking is more common than has been suggested in the occupational drinking literature. Second, workplace alcohol problems are not entirely reducible to the underlying disorders of individuals. Such problems should be seen as being behavioral in nature and, like most behavior, linked in a causal way to social and environmental contexts. The lack of awareness of on-the-job drinking is especially evident in the employee assistance program-focused literature that centers primarily on the

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implicit model of the "hidden alcoholic" employee. However, although the individual-as-deviant-or-diseased approach continues to be dominant clinically and programmatically, an alternative approach, one focusing on the environment, is gaining prominence among researchers from public health and social science backgrounds (Ratcliffe et al., 1984). For example, consumption of beverage alcohol has been studied as an artifact of cultural environments by anthropologists since the 1940s (e.g., Bunzel, 1940; Horton, 1943). Central to this cultural perspective is the idea that alcohol use is influenced profoundly by the values, beliefs, and actual practices of the members of a community. More contemporary findings of cross-cultural research conducted by anthropologists suggest that alcohol is still an important cultural artifact often well integrated into many institutions; heavy drinking is often described as more a consequence of tradition than deviance (see Bennett and Ames, 1985; Douglas, 1987; Marshall, 1979). In complex, pluralistic societies such as the United States, it is reasonable to assume that subcultural systems may derive as much from occupational affiliaton as from any other constellation of ethnic or religious factors. Certainly, career work occupies a greater amount of individuals' time and dictates social life to a greater extent than any other single institution. We found a "workplace culture" to be clearly evident in the case of assembly workers (see Janes and Ames, 1989); and T. Mannello et al. (1979), in their study of railroad workers, imply that a subcultural system of alcohol use develops among railroad workers. Moreover, in his review of the workplace drinking literature, R. Cosper offers a similar orientation when he argues that existing research may focus to an inappropriate degree on deviant drinking. He suggests alternatively that heavy drinking in some occupational groups constitutes normative behavior. Argues Cosper: "In certain occupational subcultures, drinking, rather than being viewed as pathological, may be seen as communicative behavior symbolizing social solidarity and the situation, wealth, masculinity, identity, or superiority of the group" (1979, 886). Analytic studies that attempt to identify the relationship between workplace environment risk factors and problem drinking are few in number. Mannello et al. (1979) identified four factors in the social structure of railroads that were thought to contribute to the high rate (23 percent) of problem drinking: (1) boundaries between working and not working were ill defined, (2) train operators had to travel considerably, (3) sick leave was not granted to workers, and (4) existing sanctions against on-the-job drinking were rarely enforced. Martin Plant (1979) examined brewery workers to determine whether problem drinkers selected themselves into trades where alcohol was easily available, or whether the heavy drinking rates of workers could be traced to the pressures to drink in the context of brewery work. He concluded that the latter was the more likely explanation. J. Archer (1977), in a study of blue-collar workers referred for treatment of drinking problems, found, however, that these workers differed

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very little from a nonclinical comparison group in reported level of job satisfaction. The work of H. Trice and P. Roman in the area of workplace risk factors is particularly notable (Roman and Trice, 1970; Trice and Roman, 1978). Based on a number of occupational studies, they have identified three clusters of jobbased risks for deviant drinking: (1) a lack of visibility of work activities or work performance stemming from unclear production goals, flexible work schedules, and lack of supervision, (2) stress factors stemming from the absence of structured work, including work addiction, occupational obsolescence, and job roles with which the worker has had little previous experience, and (3) an absence of effective social controls which may result in significant on-the-job drinking, and job roles where deviant drinking benefits others. Various work stresses and work conditions, including hazardous work, are also hypothesized as risks for problem drinking. D. A. Parker and colleagues have correlated work characteristics with drinking behavior and have reported problems across industries (Parker, 1979; Parker and Brody, 1982). They demonstrate in a general way that job stress, stemming either from status inconsistency or from characteristics of the work (complexity, alienation, and time pressure), predict some drinking behaviors and reported drinking problems. These findings led the authors to argue that the "alienation model" of job stress is related to alcohol problems in the same manner that it predicts psychological functioning in general (Parker and Brody, 1982; Kohn, 1976, 1977; Pearlin and Schooler, 1978). In a similar vein, M.L. Fennell, M.B. Rodin, and G.K. Kantor (1981) examined the relationship of work setting problems to the frequency of drinking and the reasons for drinking in a sample of 931 American workers. Risk factors included conflicting demands from supervisors, insufficient time to complete required tasks, and lack of help from coworkers. Although no relationship was found between these variables and the reported frequency of drinking, significant relationships were found between several work setting problems and the reasons given for drinking. Based on a review of these studies, it is possible to make four generalizations regarding the role of work in influencing drinking behavior. First, studies of alcohol treatment in industry indicate that the absence of effective social controls and the lack of visibility of a worker or his work to a supervisor or co-workers promotes deviant drinking. This is the model advanced by Roman and Trice (e.g., 1970; Trice and Roman, 1978). Second, based on research largely outside the alcohol field, particularly in mental health research, there is an indication that quality of work—job flexibility, job complexity, alienation, or lack of worker control over work conditions and products—creates a level of stress to which problematic drinking may be one response. The idea that such job conditions produce stress is the key operative concept, and most alcohol researchers have therefore borrowed heavily from socio-epidemiologic research on stress and health (e.g., Parker, 1979; Parker

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and Brody, 1982). In the alcohol field, however, there is no single, consistent definition of stress across the relevant studies. Third, suggested by R. Cosper (1979), T.C. Harford et al. (1979), O.J. Skog (1979), and others, is the idea that the differential social availability of alcohol in work-related contexts is a key determinant of individuals' drinking behavior. In this vein, certain styles of drinking are seen as normative, rather than deviant, aspects of occupational drinking subcultures (cf., Cosper, 1979). Fourth, based on our own study of assembly-line workers and their families, aspects of the social and community environment are detected that predict whether workers select involvement in occupational heavy drinking subcultures (e.g., Ames and Janes, 1987; Janes and Ames, 1989). Workers who, because of migration or other determinants, develop close-knit social networks with those at work (where co-workers become the individual's primary reference groups) are thus most likely to drink heavily. These data suggest the importance of looking at social factors in and around work as well as characteristics of the work environment itself. Scrutiny of these four generalizations reveals several apparent contradictions, for example, the normative versus deviant drinking models, the individual versus environmental risk model, and the workplace network drinking versus all network drinking. These contradictions appear to arise because of a tendency of researchers to overemphasize specific levels of analysis (e.g., the individual or the environment) or simple, linear cause-effect relationships (e.g., conditions at work and drinking). Furthermore, in nearly all the literature cited, there is a problematic assumption that work-related drinking is highly correlated with a person's nonwork drinking. Some, but not all, of these contradictory issues are addressed in the following discussion of data from our study. RESULTS OF AN ENVIRONMENTALLY ORIENTED STUDY We recently completed a study of drinking patterns and problems of bluecollar families from a population of assembly workers who were among 6,000 employees who lost their jobs when a major corporation closed one of its plants in California. The research design, which was divided into two stages, combined standard survey methods with qualitative, open-ended interviews with both husbands and wives. In the first stage we surveyed a randomly selected population of workers using a short questionnaire that included questions concerning employment history, marital status, ethnicity, religion, education, frequency and quantity of alcohol consumption for the month and year prior to the survey, and alcohol-related problems. In the second stage of the study, 30 families, 15 with a heavy-drinking father and 15 with a moderate-drinking father, were selected for intensive case studies. A heavy drinker was defined as someone who drinks at least 50 drinks a month and who reported drinking at least 6 drinks on one or more days in the month. Due to underreporting in the survey, the drinking of most of the heavy drinkers in our case studies was considerably higher than

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our established criterion, for some, 120 to 180 drinks a month. Intensive interviews during four visits to the family home were conducted with both husbands and wives. In these 30 case studies, we compared a number of alcohol-related factors between families of heavy- and moderate-drinking men. One of the most important findings of that research was that in their former workplace heavy and frequent drinking patterns were evident both on the job, as well as in work-related areas and activities. A large percentage of the workforce took part in regular work-related drinking, yet there were other workers, working side by side with the heavy drinkers, who did not drink around work at all. Another even more striking finding was that, upon leaving this particular workplace, the drinking practices of most of the drinkers changed. The literature on economic conditions and alcohol use suggests that unemployed individuals tend to drink more than the employed and report more drinking-related problems (Johnson et al., 1977; Smart, 1979). It was this literature that directed us to select our study sample from a population of assembly workers who had recently been laid off from a manufacturing plant. We believed that we would find more heavy drinkers there than in the employed group. However, we discovered that the exact opposite was the case: the majority of the workers reported that they had reduced their consumption substantially, often from heavy to moderate levels, after the layoff. Due to the availability of substantial company, union, and state unemployment benefits, which kept workers' income levels near what they had been before the layoff, reduction in consumption was not related to household economic resources. Instead, our in-depth interviews revealed that the workplace environment and work-related social networks played a central role in the development and maintenance of heavy-drinking practices. A picture of the workplace emerged from these interviews, one that suggested that heavy drinking had become normative behavior for a significant proportion of the work force. When socioenvironmental factors of the workplace were removed from the heavy drinkers' daily routine, their drinking patterns changed, that is, decreased. These and other findings from our study suggest two things about the employee population: (1) their workplace constituted an enabling environment for heavy and problem drinking, and (2) the combined forces of personal and workplace risk factors distinguished moderate from heavy drinkers.

The Workplace as an Enabling Environment For most of the heavy drinkers we interviewed, drinking was manifestly expressive of the relationship between union and management, in general, and an assertion of group independence or solidarity in the face of management demands. Several of our informants indicated that alcohol was used in defiance of a particular foreman, or it was used to express dissatisfaction with long hours or stressful working conditions. One man, a heavy drinker, described his situation as follows:

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10 or 12 of us would get together in the loading dock area on Friday nights. We'd circle our forklifts like a wagon train and there would be any kind of drugs, booze, anything you want there in the middle of those forklifts. I always had a box of ice on my forklift so I could mix a drink . . . and we'd be out there just partying down. The foreman would come and he'd beg and plead with somebody to do some work for him. Sometimes we'd do it and sometimes we wouldn't. But there was nothing they (the management) could do about it. . . things had just gotten too far out of control. He read us the riot act, told us how this department was going to start k'toeing the line" . . . but there are so many ways to stop production. He (the new foreman) lasted two or three weeks and he was literally a basket case. The third week it was just right back to drinking in front of him . . . he didn't care anymore, he just wanted the job done. These comments reveal how drinking was part of a functional trade-off between management and the workers. Foremen, in effect, were forced to be permissive in order to meet production goals. The union would always fight alcohol-related disciplinary actions, and management often would not back up the supervisors in their efforts to halt on-the-job drinking in their departments. So foremen, like the one cited above, gave in to the drinking behavior as long as the production schedule was met. Consider also the following statement of another worker: The company wasn't really stringent on those rules [about drinking], because they knew they couldn't get a lot of us to come in and do those jobs totally sober. A lot of times I think that the people that really had problems were those who had the hardest jobs. So I think management tolerated drinking a lot, not only because of the strength of the union, but because this type of job required it. And another: Let's say they come down and catch somebody drinking or using drugs, and you'd think they'd run him off, right? And the foreman's standing there yelling at him and stuff. People take their gloves off, roll them inside each other twist it and roll it back over and form a baseball, right? All of a sudden, the foreman's getting pelted with baseballs. So needless to say, they felt that their safety was going to become a very big problem if they kept harassing people for drinking. So the tendency was to not pay much attention to it. From the company's point of view the production schedule was primary and therefore one of the driving forces behind the integration of drinking into union and management power trade-offs. During some periods, often for several weeks at a time, workers would be required to work many hours of overtime. In other contexts, work conditions might be unsafe or stressful. In a tacit recognition of this fact, management was felt by workers to t4 turn a blind e y e " toward drinking in return for extensive overtime work or violations of safety regulations or work rules. In fact, the union often and explicitly used such information to negotiate dismissal of disciplinary actions taken against workers caught drinking or being intoxicated on the job. Several of the men told us that a worker would be sent

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home and suspended for a time because of an alcohol violation, but he would always be brought back by the union, often with full restitution of missed wages. According to workers (we did not interview any union officials) union representatives would threaten to enforce safety regulations in a particular area of the plant—enforcement that would cost the company production time and money— if disciplinary actions were not dropped. The lack of effective alcohol control policies in the workplace was well known to all our informants, and they were clearly aware of the message of power and defiance that on-the-job or in-the-parking-lot drinking symbolized. Drinking for some was not only a pastime but, in perhaps a more subtle sense, an avenue for expressing power, individuality, and perhaps even blue-collar solidarity in the face of management production demands (cf. McClelland et al., 1972). The instances cited above where the workers "circled the forklifts like a wagon train" or "pelted the foreman with baseballs" (rolled-up gloves) would certainly support such a hypothesis. It is also provocative to note that those men most concerned about power in the workplace were those most involved with workplace networks; that is, those who had few friendships, memberships, and affiliations outside the workplace. These men, as will be noted later on, were the heavy drinkers. Moderate drinkers were found to focus their social energies on activities and people outside the workplace, and they were relatively unaffected by the power concerns of co-workers who were more involved in the world of work. In the absence of an intensive workplace ethnography, however, which was not possible to do at the time these data were collected, this hypothesis must remain tentative.1 Workplace Drinking and Social Networks In general, the literature on occupational drinking does not make a clear distinction between on-the-job, job-related, and non-job-related drinking. Essentially, the problem is one of failing to distinguish between the varying role domains through which people move in their day-to-day lives and thus failing to specify the linkages and overlaps between them. Drinking at work, after work, at home, and at a bar on weekends with neighbors are all important phenomena to consider; in each social arena, the role, contexts, and meanings of drinking are likely to be different. It is important to recognize that urban life is a composite of roles individuals play in different social arenas or role domains (Hannerz, 1982). Several significant domains may be identified: work, leisure, family, neighborhood, kin, and community. For some individuals, particularly those in well-established, ethnically based communities, the number of people who occupy roles in these distinct domains are relatively few; that is, co-workers are neighbors, may be kin, are usually friends, and are those with whom one spends leisure time. Such networks, often termed "close-knit" (e.g., Bott, 1957), are significant insofar as the social control they exert on the network member is stronger and more

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consistent across domains than they are in looser knit networks (cf. Mitchell, 1969). With close-knit networks, there would clearly be a spillover effect of work-related drinking into the family, neighborhood, and leisure domains. Conversely, in loose-knit networks, often resulting from social or geographic mobility, the people an individual knows in the work domain are rarely contacted in roles outside that domain. Co-workers may be friendly at work, but there is no significant social interaction outside that setting. The same may be said of the community and leisure domains. In such networks the social control exerted on the network member is weak overall (though possibly significant within specific contexts), and it is not consistent across the role domains. Certain expectations about drinking may exist in one setting but not in another. For example, workers may drink together on the job, at the union hall, or at an afterwork Softball game, but the style of drinking in such settings may not carry over into the other social domains. The lack of clear distinction in the literature on work and nonwork drinking suggests the importance of eliciting information on social networks. By characterizing the shape and content of an individual's social network, it is possible to discover behavioral variations across the role domains specified above. As we discovered in the study reported in this chapter, it is important to specify clearly the differences, similarities, and overlaps between the work and nonwork worlds in terms of drinking behavior (cf. Janes and Ames, 1989). Heavy Drinkers' Networks The contexts and styles of alcohol use among the men in our 30 family case studies varied; however, characteristics shared by 14 of the 15 husbands who were heavy drinkers were their involvement in social networks comprising almost exclusively co-workers and the incorporation of regular, heavy drinking into activities—both at work and at leisure—engaged in by network members. Most of the heavy drinkers formed close-knit, work-related drinking networks while they were younger and were in the early stages of their employment at the plant. A majority (70 percent) of the adult members of our overall sample population came to this California community in the 1950s and 1960s, migrating either alone or with parents or siblings. The separation from extended family and early life peer groups and the mobility of a California suburban lifestyle caused some social disorientation and inhibited incentives to seek out replacements for the kinship, neighborhood, or religious networks left behind. Analysis of life history data showed that almost all of the men started work in the plant when they were very young and that the workplace became a convenient, if not exclusive, arena for socializing. Friendship networks at work developed into drinking networks, and thus adult socialization to drinking took place in the workplace environment. Once established, the social networks for all but one of the heavy-drinking group were limited to work peers, which created a continuum of on-the-job social interaction in which heavy and frequent drinking

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occurred. Heavy drinkers reported that their drinking sometimes began on the way to work, occurred on the job, took place through the lunch period, and continued after work in parking lots, bars, or selected homes. Off-the-job social activities with fellow workers took place in the union hall, in one another's homes on weekends, or infrequently in restaurants. At all of these events, drinking was the main activity. As discussed earlier, it is possible to conceptualize urban social relations as occurring in "domains," which may or may not overlap in terms of personnel (Hannerz, 1982). These domains include leisure, kinship, work, and so forth. The more integrated these potentially separate domains are, that is, where they share significant numbers of personnel, the greater the influences in one will influence the others. Among the heavy drinkers, where the distinction between leisure and work was blurred, the domains were linked by social networks based on work. In social network terms, relationships were "multiplex" (Mitchell, 1969), and network groups were close-knit (Bott, 1957).2 As Mitchell (1969) and Bott (1957) have noted, the consequences of closeknit networks include the development of strong intragroup behavioral norms that affect behavior and attitudes in many areas of the individual's life. Members of such groups develop consistent expectations of behavior that they apply to each other (e.g., role expectations) which supersede specific social contexts and situations. As Bott (1957) pointed out in her study of role expectations, the behavior of people who are members of a close-knit group of friends is likely to be highly influenced by the expectations of these friends. In the study reported here, these expectations can be considered to be part of the shared understandings that constitute the occupational subculture to which these workers belong. Alcohol served as the central activity and thereby the organizer for social relations of small work-based social groups. Interview material indicated that alcohol was used as a "disinhibitor," thereby facilitating interpersonal emotional expression; it was an important element in these worker networks. The following comments by heavy drinkers illustrate these points: [The plant] was unreal. I mean it's a city within its own. It would amaze people what goes on inside that plant. People could bring cases of beer in if they wanted to. . . . I began drinking heavy when I started at the plant. That was basically part of my downfall, maybe. . . . It's just the people that you hang around with out there. You know, it's a party in life. Drinking played a very heavy part of your existence at the plant. What percentage, I don't know, but I'll tell you one thing, it was a very large one. I was one of the victims . . . or one of the participants... I made a pretty remarkable recovery [from the heavy drinking]. I think the will was always there, but it's hard when you're surrounded by people that do the same thing you do. I think it's the camaraderie that goes on in this type of atmosphere. You don't want to let go. There's safety in numbers. A lot of your buddies had problems drinking too, and it was something you always did together. Everybody was real personal and confidential when you were drinking together.

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Wives were occasionally included in these activities, but for the most part, heavy-drinking friendship groups tended to be male oriented. Wives of heavy drinkers complained about the exclusivity of this friendship network and often attempted, usually with little success, to limit their husbands' participation in it. In some cases, wives rebelled against these drinking networks by demonstrating reluctance or outright refusal to participate in work-related social activities—even when other wives were included—or disallowing such social gatherings in their own homes. The degree to which such drinking networks diminished the heavy drinkers' involvement in family life is demonstrated in the following statement by one wife: It was just drink, come in and have a drink; that's what you did with these people. First of all I stopped going to the ball games with him; then we stopped socializing as a couple with people we had been seeing; that put a lot of pressure on my husband because when he went somewhere he wanted me and the kids to be with him and I wouldn't do it. I didn't like him having his friends over here; I didn't like the kids being around them. It ended up that I had fights with these people a lot of times, telling them I thought they were stupid for doing the things they did, and to stop foulmouth talking around my kids. I'd tell them to leave . . . so he stopped bringing them here. The level of involvement in family, community, and voluntary organizations, particularly those that led to the development of nonwork-related social networks for men and their wives, emerged as a major difference between moderate and heavy drinkers: only 7 percent of the heavy drinkers had involvement in nonworkrelated social activities, whereas 60 percent of moderate-drinking families were involved in formal or informal group activities on a regular basis. Moderate Drinkers' Networks Analysis of the interviews of the moderate drinkers suggests a very different pattern of relationships to work and co-workers. Of the 15 moderate drinker case studies, only three men reported social involvement with co-workers outside the workplace. The social lives of the moderate drinkers were dominated by activities and involvements that were unrelated to their roles in the workplace. Moderate drinkers typically spent little time before or after work socializing with co-workers, and few had established close friendships in the workplace. Rather, for this group and their families, work as a social domain was not integrated with the leisure domain. Pleasures, satisfactions, and personal interests were pursued in the context of joint family activities such as religious-oriented groups or formal organizations, such as 4-H clubs, Girl Scouts, or recreational vehicle clubs, antique, or hot-rod car clubs, and informally organized activities such as hunting and sports groups. The drinking that moderate drinkers did occurred primarily in the context of these leisure activities, in which drinking was not a major, integrative element.

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In contrast to the heavy drinkers, moderate drinkers resisted pressures to drink on and off the job with co-workers from early on in their work experience. They made an effort, sometimes with great difficulty, to establish social involvements that were nonwork related. In the process, they, with their families, established friendship and community networks that appear to have offered protection in that they superseded workplace-related drinking networks and offered incentives for fathers to spend evenings and off-hours in family- and community-involved activities. The moderate drinkers as a group were not overinvolved in their work. In general, they expressed the attitude that, although the job was not great and they disliked some of the people they had to work with, the high wages and benefits of the job gave them the opportunity to pursue those leisure activities they enjoyed. For example, one man intensively involved in club and social activities with his family noted: Basically, I liked my job. I seem to be happy with just about any job I have so long as I am making good money. You know, a lot of times they say that's not an attitude to have, but it seems to work for me. . . . Yeah the work was OK, just some of the people messed it up. Moderate drinkers clearly did not evince the same degree of despair with their work as did heavy drinkers, and many had the attitude that "work was work," and that you sought your personal satisfactions elsewhere—in your family, in your community, or within yourself. This attitude suggests that the moderate drinkers had a more balanced social and emotional investment in the workplace domain. This balanced investment made workplace pressures relatively less salient in psychological and sociocultural terms. To paraphrase one moderate drinker, when the shift was over you left work behind in favor of more pleasurable activities. SUMMARY AND IMPLICATIONS FOR INTERVENTION As further evidence of the salience of the work environment in promoting high levels of drinking, we again note that it is remarkable that nearly all the heavy drinkers, and even some of the moderate drinkers, reduced drinking when the plant closed down. The reasons workers gave for reducing their drinking fell into one or more categories of explanation. First, several individuals took new jobs which did not permit or include drinking, or they found themselves so busy that they did not have the time to drink. Second, most individuals lost the drinking friends they had made at the plant, and with the lack of opportunity or the appropriate social context for drinking, consumption simply declined. Although many workers tried to keep in touch with their friends, the company transferred several hundred employees out of state, and this, combined with new work and

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family demands, made continued association with co-workers at the previous level nearly impossible. Furthermore, several distinct social and psychological characteristics mark the difference between the moderate and heavy drinking groups. Heavy drinkers socialized almost exclusively with co-workers both on the job and in leisure domains. The primacy of worker groups entailed strong pressure to conform to a heavy-drinking norm. In addition to being a central element of group behavior, such drinking also served to reduce boredom and dissatisfaction with work and to express solidarity and group power in a world whose parameters were constructed by the upper, "white-shirted" echelons of the corporation. To the heavy drinkers, work was an all-encompassing environment with which one struggled and in which one found like-minded compatriots with whom to share such struggles. Drinking was clearly a significant element in this struggle. Given the nature of alcohol use in the plant, and the possible personal and group functions it served, it is significant that when the plant closed the majority of the heavy drinkers reduced their drinking considerably. Moderate drinkers, on the other hand, were not involved in the world of work to nearly the same degree. There was little overlap in the social domains of work and leisure, and consequently the workplace domain supplied relatively fewer pressures on individual behavior and choice. Moderate drinkers had less to say about the pressures of the job; instead, they sought personal satisfactions elsewhere, often in their families, or in extra-work organizations, hobbies, or pastimes. A question that emerged in our research was whether work-related environmental factors caused heavy drinking or were simply permissive of heavy-drinking tendencies. A scrutiny of the drinking histories of individual workers suggested that the workplace may facilitate drinking problems because it enables the development of heavy-drinking groups and practices. We concluded that the enabling seems to be as much a matter of sanctioning drinking (however covertly) as part of structural power trade-offs and strategies to placate unhappy workers, as it is of groups coming together and, whatever the process, developing a set of shared understandings that drinking is, in effect, a good and necessary thing. It would thus seem feasible to consider what steps might be taken to reduce the opportunities for heavy or problem drinking at work, regardless of the influences stemming from social involvements outside of this context. When we focus on the role of environmental factors in workplace drinking, we gain new understandings about how such drinking may be an outcome of a complex set of interrelationships between the work environment, the social organization of work, the evolution of informal groupings at work, other social spheres of the worker's life, and specific characteristics of the worker him or herself. Such a conceptual model has productive implications for various people and agencies concerned with organized treatment and primary prevention in the workplace including employee assistance programs (EAP), medical personnel, health and safety teams, union representatives, company policymakers, and, of course, researchers.

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At the organizational level, it has the potential for providing corporate and union leaders with a set of guidelines for diagnosing how the workplace contributes to the development of alcohol problems. Following diagnosis, it also provides direction into the most critical areas where there is a need to change physical and structural characteristics of the workplace environment and to establish alcohol-related policies that inhibit the development of on-the-job or jobrelated drinking. At the level of EAP and other workplace treatment and policy prevention personnel, this approach should provide a solid base for complementing models focused on diagnosis, treatment, and rehabilitation of the individual as a sick or weak worker, by including a program of diagnosis, change, and reformulation of the environment in which the drinking occurs. Hopefully, the findings from our current study—and others like it—will provide much more detailed data on the kinds of questions to be asked of both employee and employer. While interventionists cannot treat the entire universe of enabling environments, they should at least have some basic knowledge of risk factors and protective factors from the various environmental circumstances presented here and understandings of where and how they overlap. To attempt treatment and rehabilitation of an employee who regularly returns to environments that support his or her drinking is difficult, to say the least. NOTES Preparation of this paper was supported by the National Institute on Alcohol Abuse and Alcoholism Research Center Grant AA06282-05. The authors wish to thank William Delaney and Paul Roman for their helpful comments and suggestions. 1. The present research of the authors includes an extensive worksite ethnography. 2. This discussion cannot do justice to social network theory. The reader is urged to consult Mitchell (1969) for a good review of basic concepts and the early work in urban anthropology that applied these concepts. Basically, he distinguishes between the structure of networks, or morphology, and the interactional nature of the relationships, or content. The idea of close knit includes both concepts: first, heavy drinking networks are morphologically dense in that they include people who all know each other (i.e., primary groups); and second, the content of these networks is multiplex in that relationships are based on cooperation in work or work-related (union) affairs, as well as on friendship and occasionally kinship.

REFERENCES Ames, G. (1989). Alcohol-related movements and their effects on drinking problems in the American workplace; A historical review. Journal of Drug Issues, 19 (4), 489-510. Ames, G., and Janes, C. (1987). Heavy and problem drinking in an American blue collar population; Implications for prevention. Social Science and Medicine 25 (8), 949960.

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Archer, J. (1977). Social stability, work force behavior, and job satisfaction of alcoholic and non-alcoholic blue-collar workers. In C.J. Schramm (Ed.), Alcoholism and its treatment in industry (pp. 156-176). Baltimore, MD; Johns Hopkins University Press. Bennett, L., and Ames, G. (Eds.). (1985). The American experience with alcohol: Contrasting cultural perspectives. New York: Plenum Press. Bott, E. (1975). Family and social network. London: Tavistock Institute of Human Relations. Bunzel, R. (1940). The role of alcoholism in two central American cultures. Psychiatry, 3, 361-387. Cassel, J.C. (1976). The contribution of the social environment to host resistance. American Journal of Epidemiology, 104, 107-123. Cosper, R. (1979). Drinking as conformity: A critique of sociological literature on occupational differences in drinking. Journal of Studies on Alcohol, 40, 868-891. Douglas, M. (Ed.). (1987). Constructive drinking: Perspectives on drink from anthropology. New York: Cambridge University Press. Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Journal of Science, 196, 129-136. Fennell, M.L., Rodin, M.B., and Kantor, G.K. (1981). Problems in the work setting, drinking, and reasons for drinking. Social Forces, 60, 114-132. Hannerz, U. (1982). Tales of the city: Inquiries toward an urban anthropology. New York: Columbia University Press. Harford, T . C , Parker, D.A., Pautler, C , and Wolz, M. (1979). The relationship between the number of on-premise outlets and alcoholism. Journal of Studies on Alcohol, 40(H), 1053-1057. Harrington, C , Mosher, J., and Colman, V. (1987). Alcohol in the workplace and employer liability: Legal theories and policy recommendations. Western State Law Review, 14 (2), 375-408. Horton, D. (1943). The functions of alcohol in primitive societies: A cross-cultural study. Quarterly Journal of Studies on Alcohol, 4, 199-320. Janes, C , and Ames, G. (1989). Men, blue collar work and drinking: Alcohol use and misuse in an industrial subculture. Culture, Medicine and Psychiatry, 13, 245274. Johnson, P.J., Armor, D.J., Polich S. et al. (1977). U.S. adult drinking practices: Time trends, social correlates and sex roles. Springfield, VA: U.S. National Technical Information Service. Kohn, M.L. (1976). Occupational structure and alienation. American Journal of Sociology, 82, 111-130. Kohn, M.L. (1977). Class and conformity: A study in values (2d ed.). Chicago: University of Chicago Press. Levine, H. (1984). The alcohol problem in America: From temperance to alcoholism. British Journal of Addiction, 79, 109-119. Mannello, T., Paddock, J., Wick, W., and Seaman, J. (1979). Problem drinking among railroad workers: Extent, impact and solutions. Washington, DC: University Research Corporation. Marshall, M. (Ed.) (1979). Beliefs, behaviors, and alcoholic beverages: A cross-cultural survey. Ann Arbor, MI: University of Michigan Press. McClelland, D.C., Davis, W.N., Kalin, R., and Wanner, E. (Eds.).(1972). The drinking man: Alcohol and human motivation. New York: The Free Press.

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Mitchell, J.C. (1969). The concept and use of social networks. In J. Clyde Mitchell (Ed.), Social networks in urban situations (pp. 1-50). Manchester, England: Manchester University Press. Parker, D.A. (1979). Status inconsistency and drinking behavior. Pacific Sociological Review, 22, 77-95. Parker, D.A., and Brody, J.A. (1982). Risk factors for alcoholism and alcohol problems among employed men and women. In Occupational alcoholism: A review of research issues (NIAAA Research Monograph No. 8, pp. 99-127). Washington, DC: U.S. Government Printing Office, USDHHS. Pearlin, L.L., and Schooler, C.S. (1978). The structure of coping. Journal of Health and Social Behavior, 19, 2-21. Plant, Martin A. (1979). Drinking careers: Occupations, drinking habits, and drinking problems. Cambridge, England: University Press. Ratcliffe, J., Wallack, L., Fagnani, F., and Rodwin, V. (1984). Perspectives on prevention: Health promotion vs. health protection. In J. de Kervasdoue, J.R. Kimberly, and V.G. Rodwin (Eds.), The end of an illusion (pp. 56-84). Berkeley, CA: University of California Press. Roman, P.M., and Trice, H.M. (1970). The development of deviant drinking behavior. Archives of Environmental Health, 30, 424-435. Skog, O.J. (1979). Social interaction and the distribution of alcohol consumption. (Mimeo No. 30). Oslo, Norway: National Institute for Alcohol Research. Smart, R.G. (1979). Drinking problems among employed, unemployed, and shift workers. Journal of Occupational Medicine, 21, 731. Staudenmeier, W.J., Jr. (1985). Alcohol and the workplace: A study of social policy in a changing America. Unpublished doctoral dissertation, Washington University, St. Louis, MO. Trice, H., and Roman, P. (1978). Spirits and demons at work: Alcohol and other drugs on the job. New York: New York State School of Industrial and Labor Relations, Cornell University.

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8 BUSINESS AND PROFESSIONAL WOMEN: PRIMARY PREVENTION FOR NEW ROLE INCUMBENTS ELSIE R. SHORE

Today, greater numbers of women are being given access to and are accepting professional and high-level business positions. Along with the key to the executive suite come new expectations, stresses, roles, responsibilities, and perhaps heightened vulnerability to illness and disease. Researchers and practitioners in the alcohol-abuse field have expressed concern that women in managerial, administrative, and other professional positions may be at increased risk for the development of alcoholism and other alcohol-related problems. A number of factors have been hypothesized as causes of alcohol problems among women who work outside of the home. These include sex-role conflict and threats to feminine identity, occupational and other stresses, discrimination against women, and the effect of the adoption of multiple roles. For the prevention worker, the workplace researcher, or the employee assistance program staff person, the most useful approach may be to look at the role of workplace norms and expectations on drinking behavior. Women taking business and professional jobs are joining groups that already have norms about the use of alcohol in business and at business-related social occasions, and they may be expected to follow these rules. Even without overt or covert pressure to conform, the newcomers may desire to adopt prevailing behaviors in order to fit in and be accepted by peers and superiors. Unfortunately, the drinking norms associated with many workplaces have been linked with the development of alcohol problems. Because the new role incumbents are different from past and present employees, the organization and its members may be unsure whether prevailing norms should apply to them. Although the lack of guidance about appropriate behavior may permit greater individual freedom, it also has been linked to alcohol misuse (Larsen and Abu-Laben, 1973; Straus and Bacon, 1953). Thus, both the

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lack of clear norms and the conformity to existing, unhealthy norms have been viewed as increasing vulnerability to heavy or problem drinking (Johnson, 1982; Noel and McCrady, 1984; Whitehead and Ferrence, 1977). It should be noted that not all researchers agree that societal changes in women's opportunities will lead to heavier drinking and increased alcoholism (Beckman, 1978; Wilsnack, 1976). When the predictions and warnings first appeared, research in the area was extremely limited. One purpose of the studies presented here was to obtain data on consumption and negative consequences of alcohol use and norms concerning alcohol use in business settings. The goal of this data collection is to determine the need for primary prevention activities directed at women in business and professional positions. Primary prevention is work done to prevent the development of problems among people who do not already show evidence of them. Secondary and tertiary prevention, targeting people who show some degree of impairment or fully developed disease states, will not be addressed here, except to state that such efforts are as important for women as they are for men.

SAMPLE 1: BUSINESS AND PROFESSIONAL WOMEN AND MEN Subjects in the first sample were 147 women and 94 men employed in business and professional jobs in Wichita, Kansas. In contrast to the image of Kansas and the agricultural nature of most of the state, Wichita, population 280,000, is a metropolitan area. The major employer, the aircraft industry, including plants and offices of Boeing, Beech, Cessna, and Learjet, requires engineers and professionals as well as machinists and assembly workers. Although it may be questionable to generalize from subjects in Wichita to workers in extremely large metropolitan areas such as New York and Los Angeles, there are numerous other medium-sized cities in the United States where thousands of women and men work under conditions similar to those in Wichita. The men and women in this sample were recruited through professional organizations, including groups for personnel and public administrators, attorneys, accountants, advertising personnel, managers, and business owners. They were asked to complete a survey which included demographic questions, a measure of alcohol consumption, an alcohol information questionnaire, and a measure of norms about drinking. The average age of the participants was 38.5 years, with a range from 22 to 74 years. Most were white (91.9 percent) and Protestant (55.9 percent). Most (69.2 percent) were married, but there were proportionately fewer married women than married men. None had less than a high school education, and 39.3 percent had completed college. Most described their jobs as managerial, professional, or administrative. (For more details on this study and its results, see Shore, 1985a, b, c.)

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Table 8-1 Quantity-Frequency of Alcohol Consumption, Sample 1 Quantity-Frequency Abstainer Infrequent Light Moderate Heavy

Men N 5 7 45 18 18

%

5.3 7.4 47.9 19.1 19.1

Women N % 5 25 70 31 16

3.4 17.0 47.6 21.1 10.9

SAMPLE 2: LONGITUDINAL STUDY OF BUSINESS AND PROFESSIONAL WOMEN The second sample also comprises people working in Wichita and the vicinity. The 494 women in this sample are part of a three-year primary prevention project, targeting business and professional women, funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The data presented here are from a preintervention survey. The survey, which covered a number of areas in addition to alcohol use and norms, was mailed to 770 women who were recruited primarily through professional organizations. The average age of the women in this sample is 40, with a range from 20 to 92 years. The overwhelming majority (96 percent) are white, and most (65 percent) are married. The group is highly educated; 45.0 percent have earned a master's degree or beyond. Over half of the participants earn more than $20,000 per year, and more than 5 percent are in the $50,000+ salary range. ALCOHOL CONSUMPTION A quantity-frequency scale (Jessor et al., 1968) was used to measure alcohol consumption in both samples. In the first group, 93.6 percent of the men and 96.6 percent of the women reported at least infrequent drinking. The proportion of male heavy drinkers was almost twice that of female heavy drinkers (Table 8-1). Proportionately more women than men were infrequent drinkers. The statistically significant correlation between age and consumption, with the latter declining as age increases, mirrors findings of other studies (e.g., Cahalan and Room, 1972; Cooke and Allen, 1983; Hingson, Mangione, and Barrett, 1981). There were significant relationships between alcohol consumption and marital status, a result also consistent with other research (Cahalan, Cissin, and Crossley, 1969; Johnson, 1982; Wechsler, 1978). Among the women, 18.2 percent of those who were never married, divorced, or separated were heavy drinkers, compared with 6.5 percent of the married women. There were more abstainers and fewer self-reported heavy drinkers in the second sample (Table 8-2), but the high numbers of business and professional women who drink at least infrequently remained. Recent surveys, including large

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Table 8-2 Quantity-Frequency of Alcohol Consumption, Sample 2, Women Only Quantity-Frequency Abstainer Infrequent Light Moderate Heavy

N

%

42 107 259 60 18

22.0 53.3 12.3

8.6

3.7

national surveys in the United States, have found drinking rates from 56 to 80 percent for women (Gomberg, 1982; Hingson, Mangione, and Barrett, 1981; Smith, 1981; Wechsler, 1978). The prevalence of drinking among employed women appears to be higher (Parker et al., 1983) than in the total adult female population. The women in the two samples show an even higher proportion of drinking members than those found in other studies. The heavy-drinking rates of 3.7 percent and 10.9 percent found in these samples appear to be comparable to the rates reported in other studies (Johnson, 1982; Smith, 1981; Wechsler, 1978), but the low number of abstainers in these groups affects the interpretation of the data. In P.B. Johnson's (1982) study, for example, exclusion of abstainers from computation raised the proportion of heavy drinkers from 9 to 16 percent. Exclusion of abstainers in the present samples raises the proportion a negligible amount. The increase in numbers of women who are drinking alcoholic beverages does not appear to be accompanied, as some have predicted (Whitehead and Ferrence, 1977), by increases in numbers of heavy drinkers. The women in these groups do not appear to be adopting the drinking patterns of men or turning to alcohol to handle stress. Perhaps these women recognize that nonabstention is the norm in the business world, but they also retain female norms for the amount of consumption. In other words, they may perceive that one must drink to be one of the boys, but one must still drink like a lady. NEGATIVE CONSEQUENCES OF ALCOHOL CONSUMPTION The amount of alcohol a person drinks is not as important as the effect alcohol has on her life. Subjects in the second sample were given a list of negative consequences of alcohol use and uses that are linked with unhealthy drinking, and they were asked how often in the last six months they had experienced these effects. The most frequently endorsed items (Table 8-3) indicate the use of alcohol to alter mood or forget problems. These uses, which are linked with alcohol problems and alcoholism, are found more commonly among women than among men. The next two most frequently endorsed negative behaviors, being a passenger in a car driven by a drunk driver and driving while intoxicated, may signal the

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Table 8-3 Negative Consequences of Alcohol Use Use/Consequence

D r i n k to become less d e p r e s s e d , get r i d of " b l u e " or sad feelings. To ease physical pain, get to sleep. To f o r g e t problems at home or at w o r k . Passenger in a car d r i v e n by someone you f e l t was h i g h or d r u n k . Drove a car when you f e l t d r u n k or high from d r i n k i n g . Drank while on medication not to be mixed with aicohol. D r i n k i n g i n t e r f e r e d with homemaking. Got d r u n k / h i g h in s i t u a t i o n in which it would have been b e t t e r to stay sober.

Reported at least once in last six months N % 116 93 91

23.8 19.0 19.0

73

15.0

61

12.5

37 34

7.6 7.0

26

5.3

development or exacerbation of new problems for women. Business and professional women may be involved in more events that lead to driving after drinking or being a passenger of drinking drivers than are homemakers or women in other jobs. A woman leaving a work-related social occasion alone, in a city with little or no public transportation, may feel she has very little choice but to drive. If she is offered a ride by her alcohol-impaired boss or supervisor, will she be able to refuse? Another negative consequence of importance is the effect of alcohol misuse on health. There is some evidence that suggests that women may be more vulnerable to health consequences, such as cirrhosis of the liver, than are men. The women were asked to rate their health as excellent, good, fair, or poor. Subjects usually respond to this type of scale by choosing either excellent or good, and this held true for this sample. Despite the response bias there were differences in self-reported health based on consumption level. Slightly more than 73 percent of the moderate drinkers rated their health as excellent; 55.6 percent of the heavy drinkers rated their health as good or fair. Ratings of abstainers, infrequent, and light drinkers were relatively evenly divided between excellent and good or fair. Thus, even with a relatively crude measure, an important negative consequence of heavy drinking, the deterioration of health, is evident. MULTIPLE ROLES AND DRINKING Concern has been expressed that the woman who takes on multiple roles (i.e., wife, mother, and working woman) will respond to the demands placed on her by drinking. Three variables in the questionnaire given to the second sample of women could be viewed as measures of role overload or role conflict. The relationship between the three variables and alcohol use and negative consequences was investigated.

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The number of children subjects had correlated with both consumption and negative consequences, but the relationship was inverse. As the number of children increased, both consumption and number of negative consequences decreased. The women were asked to list all the major time-consuming roles they have. Again, the correlations between roles and consumption and roles and negative consequences were inverse. There was no statistically significant correlation between the number of organizations the women belonged to and alcohol consumption, but there was a significant, and again inverse, relationship between organization membership and negative consequences and uses of alcohol. R.W. Wilsnack and R. Cheloha (1987) also have found that multiple roles do not correlate with alcohol problems. They found that the opposite, a lack of meaningful and fulfilling roles, may be linked with problem drinking. In addition to the rewards that come from a full and diverse life, the woman with many roles simply may not have time for much drinking. Alternatively, the heavydrinking woman may abandon or lose some of her roles as her drinking becomes more important to her. DRINKING COMPANIONS, SETTINGS, AND ON-THE-JOB DRINKING Social inducement to drink may be important in understanding women's drinking. Being in the company of drinkers may lead the woman to drink or to drink abusively. In addition, characteristics of the social context and drinking was investigated with the second sample of business and professional women. Subjects were asked to rate the drinking of their spouse and their best friend. Rated level of consumption was significantly related to the subject's consumption and to the number of negative consequences and use of alcohol. As the spouse's and best friend's drinking increased, the woman's drinking and negative consequences increased. The women were asked how often in the last 30 days they were in settings where other people were drinking, regardless of their own drinking behavior. Greater frequency in drinking settings was positively correlated with both consumption and negative consequences. One hundred of the women (20.9 percent) responded affirmatively when asked if drinking was permitted or expected as part of the job. The women in this group had more negative consequences than those for whom on-the-job drinking was not expected or permitted. Looking at the individual negative consequences that were related to on-the-job drinking it was found that driving while intoxicated and riding with an intoxicated driver were reported more frequently (Table 8-4). This seems to be a logical relationship inasmuch as job-related drinking occurs outside the home and sometimes away from the office and, therefore, requires transportation. The relationships found between drinking and negative consequences and the

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Table 8-4 Some Negative Consequences Related to On-the-job Drinking Consequence

D r i v i n g while impaired Passenger of impaired d r i v e r

Drinking Permitted/Expected Yes No N % N % 20 22

20 22

39 51

10.4 # 13.6 + * P-.01 + P-.04

above-mentioned variables suggest that the milieu in which the woman lives and works can affect her use of alcohol and can increase her vulnerability to abusive drinking and dangers such as drinking and driving. Job characteristics and company policies can expose workers or protect them from harm and should be considered as targets for prevention activities. NORMS ABOUT DRINKING IN BUSINESS Some time ago E.H. Mizruchi and R. Perrucci (1962, 1970) conceptualized drinking norms as prescriptive or proscriptive and found correlations between norm types and prevalence of drinking problems. Proscriptive norms, which direct people to abstain, avoid, or reject a behavior, and are linked with problems with alcohol, were thought to provide the person who chooses to drink with no models of safe drinking. Prescriptive norms, which instruct drinkers in acceptable ways in which to engage in the behavior, were found in groups showing low levels of pathological drinking. D.E. Larsen and B. Abu-Laben (1973) added a third norm type, the nonscriptive norm, which neither forbids nor provides adequate guidelines for use; this has also been linked to heavy or problem drinking. Nonscriptive norms may be common in the United States, where ambivalence or conflict about the acceptability of drinking is widespread. Studies of norm qualities tend to focus on large segments of society, such as religious and ethnic groups, but family, friends, college environments, and groups of age peers have been studied as well (Abu-Laben and Larsen, 1968; O'Brien, Rossi, and Tessler, 1982). The work environment can also have norms about drinking that are transmitted to members and influence their behavior. To study this, the men and women in the first sample were given Wvt vignettes in which a business person was in a situation that combined business and alcohol consumption and were asked to evaluate the situation. The vignettes varied in the amount of consumption depicted. The first portrayed an attorney having one drink, the second showed a salesperson becoming somewhat drunk, the third portrayed a manager having coffee while others have a drink, the fourth showed the protagonist stopping for a few drinks to unwind after work, and the fifth

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Table 8-5 Reactions to Business Drinking Vignettes

Vi y r i e t t e s

Subjects Male Protagonists Male Fern ale no c o n s e n s u s

1.

One D r i n k

2.

SoiTiewhat drunk

negative

3.

Abstaining

positive

4.

Durinking to unwind

negative

5.

3-4

n e y a t i ve

drinks

no c o n s e n s u s

Female Protagonists Male Female neutral

neutral

negative

negative

negative

neutral

positive

neutral

negative

no c o n s e n s u s

no c o n s e n s u s

negative

negative

n e y a t i ve

vignette involved the main character having three or four drinks at a dinner with clients. The gender of the protagonists was varied by changing names and pronouns in the stories. Male and female versions of the stories were distributed randomly to male and female subjects. Becoming drunk at a company party and having three or four drinks while entertaining clients was viewed as negative for men and women by both male and female subjects (Table 8-5). Drinking to unwind after work was viewed as negative for men by both men and women, but no consensus was reached on the evaluation of this behavior when exhibited by a woman. The male manager who drank coffee was viewed positively by both men and women, but when the manager was female she was given neutral ratings. The situation that produced the least clear reaction was the one in which the protagonist had one drink at lunch with clients. Except for the abstaining situation, having one drink could be viewed as least dangerous to personal health and safety and to the conduct of business, as well as being a situation with which the primarily nonabstaining subjects probably were familiar. Positive reactions to the vignettes can be conceptualized as indicative of prescriptive norms, negative reactions as evidence of proscriptive norms, and lack of consensus or neutral evaluations as evidence of the absence of a clear norm or of ambivalence about the behavior. With the exception of heavier drinking (getting somewhat drunk and having three or four drinks), reactions to women in drinking situations related to business showed a lack of clear norms. Both male and female subjects appeared to be unsure of what constitutes proper drinking behavior for women. Given prior research linking the absence of norms with drinking problems, the women in this study could be considered to be at greater risk for the development of alcoholism and other problems.

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SUMMARY AND IMPLICATIONS Some of the major results of the study of these two groups of business and professional women can be summarized as follows: • The proportion of drinkers, that is, women who drink at least occasionally, among business and professional women is high and comparable to numbers of nonabstaining men in similar positions. • Although the majority of the women drink, the amount they report that they drink is less than that of their male counterparts. • The women report using alcohol to alter moods and forget problems. Driving while intoxicated or riding with an intoxicated driver was a relatively common negative consequence, possibly linked to job-related transportation needs. • Having a number of time-consuming roles was correlated with lower alcohol consumption levels and fewer negative consequences of alcohol use. • Drinking levels of friends and spouse were positively correlated with the women's level of consumption. • Being in a work environment in which drinking is permitted or expected was correlated with the presence of negative consequences, especially drinking and driving. • There is a lack of clear, helpful norms regarding the proper drinking behaviors for women in work-related situations. Instead of viewing drinking behavior as governed solely by internal psychological needs or family history, we can profitably look at the current social and work environment as a factor in determining how a woman will drink. In our sample the women's consumption was related to that of their spouses and best friends. The working woman spends a great deal of her time with her colleagues and co-workers. There is no reason to doubt that their behavior also can influence her drinking. In addition to the influence of other individuals in the workplace, the policies and practices of the organization can affect the worker. The women working in companies where drinking is permitted or expected showed negative consequences of alcohol use, including drinking and driving, a behavior not usually associated in people's minds with women. N.E. Noel and B.S McCrady (1984), in an article on alcohol-abuse prevention, suggest that an attempt to establish new drinking norms for women, especially within small, circumscribed groups, is an achievable goal. Work settings may be well suited to Noel and McCrady's suggestion. While at present it appears that both men and women do not have a sense of what are proper drinking behaviors for women in business-related situations.„it is unlikely that this state of normlessness or normative flux will last. Before unhealthy norms, such as those correlated with men's alcohol problems, are transmitted to women, we can work to establish norms that will be safe and

122

Social and Organizational Contexts

healthy for workers of both genders. Companies can look at their policies regarding drinking on the job or at job-related functions and ways that they deal with the person whose drinking is impairing her or his functioning on the job. Unwritten, informal messages about drinking are equally powerful and can be altered to reflect concern about alcohol abuse and the place of drinking in work situations. One area particularly amenable to change is that of drinking and driving, especially in light of legal liability questions and the possibility of costly damage awards. Policies can be instituted about driving company vehicles and driving for business. Designated driver arrangements can be made and encouraged by employers so that they begin to become the norm at work. Company-sponsored events can be planned to downplay the importance of drinking in favor of other activities, and arrangements can be made in advance to ensure that impaired guests do not drive. Concern that women entering the workplace will be vulnerable to alcoholism and alcohol-related problems predates research on the issue. It has expressed itself in comments that alcoholism is the price of women's liberation and in discussions of the impact of the stress of multiple roles that women must adopt to include work in their activities. My research and that of others (Fillmore, 1984; Wilsnack and Cheloha, 1987) suggests that this is not the case. The women in my second sample showed less consumption and fewer negative consequences of alcohol use the busier they were. Researchers at the Wichita State University, who used the same sample and studied other aspects of the women's lives, agree that the subjects are saying that, although balancing multiple roles and heavy schedules of work and family responsibilities is difficult, they are thriving on the diversity in their lives. K.M. Fillmore suggests that the concern about deviant drinking among working women may reflect anxiety about having the "carrier of the moral torch and protector of the home" (Fillmore, 1984, 22) entering the man's sphere, and that the message actually is "stay home." Whether from a desire to protect women or discomfort in having them in the office as peers, acting on the notion that women will be vulnerable to alcohol or other problems if they are given the same opportunities and responsibilities as men limits their ability to contribute to their companies and experience the excitement of a challenging job. The powerlessness and frustration of functioning below one's ability may, in fact, contribute to the misuse of alcohol among women. The assumption made in this discussion is that the workplace will influence the woman to change her drinking behaviors, but we should not neglect to consider the effect that the presence of women and the values they bring can have on the work environment. It is unlikely that one woman can have a large effect, unless she is in a position of considerable power and authority. Once women are part of the managerial and professional ranks in more than token numbers, and if they retain their moderate alcohol consumption habits (which preliminary data suggest they are doing), they could alter workplace norms and

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behaviors. If women are not pressured into adopting male standards and are encouraged to use their own styles of working and interacting, they might demonstrate the value of their moderate usage and transform the workplace into a healthier, more productive milieu for both men and women and for the business and professional community. NOTE Support from Grant No. R23-AA-06912 from the National Institute on Alcohol Abuse and Alcoholism is gratefully acknowledged.

REFERENCES Abu-Laben, B., and Larsen, D. (1968). The qualities and sources of norms and definitions of alcohol. Sociology and Social Research, 53, 34-43. Beckman, L.J. (1978). Sex role conflict in alcoholic women: Myth or reality. Journal of Abnormal Psychology, 87, 408-417. Cahalan, D., Cisin, J.H., and Crossley. H.M. (1969). American drinking practices: A national study of drinking behaviors and attitudes. Rutgers Center of Alcohol Studies Monograph No. 6. New Brunswick, NJ. Cahalan, D., and Room, R. (1972). Problem drinking among American men aged 2 1 59. American Journal of Public Health, 62, 1473-1482. Cooke, D.J., and Allen, C.A. (1983). Self-reported alcohol consumption and dissimulation in a Scottish urban sample. Journal of Studies on Alcohol, 44, 617-629. Fillmore, K.M. (1984). When angels fall: Women's drinking as cultural preoccupation and as reality. In S.C. Wilsnack and L. Beckman (Eds.), Alcohol problems in women. New York: Guilford. Gomberg, E.S.L. (1982). Historical and political perspective: Women and drug use. Journal of Social Issues, 38, 9-23. Hingson, R., Mangione, T., and Barrett, J. (1981). Job characteristics and drinking practices in the Boston metropolitan area. Journal of Studies on Alcohol, 42, 723738. Jessor, R., Graves, T.D., Hanson R.C., and Jessor, S.L. (1968). Society, personality, and deviant behavior: A study of a tri-ethnic community. New York: Holt, Rinehart & Winston. Johnson, P.B. (1982). Sex differences, women's roles and alcohol use: Preliminary national data. Journal of Social Issues, 38, 93-116. Larsen, D.E., and Abu-Laben, B. (1973). Norm qualities and deviant drinking behavior. In P.C. Whitehead, C F . Grindstaff, and C.L. Boydell (Eds.), Alcohol and other drugs: Perspectives on use, abuse, treatment and prevention. Toronto, Canada: Holt, Rinehart & Winston of Canada. Mizruchi, E.H., and Perrucci, R. (1962). Norm qualities and differential effects of deviant behavior: An exploratory analysis. American Sociological Review, 27, 391-399. Mizruchi, E.H., and Perrucci, R. (1970). Prescription, proscription, and permissiveness: Aspects of norms and deviant drinking behavior. In G.L. Maddox (Ed.), The domesticated drug: Drinking among collegians. New Haven, CT: College and University Press.

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Noel, N.E., and McCrady, B.S. (1984). Target populations for alcohol abuse prevention. In P.M. Miller and T.D. Nirenberg (Eds.), Prevention of alcohol abuse. New York: Plenum. O'Brien, L.J., Rossi, P.H., and Tessler, R.C. (1982). How much is too much?: Measuring popular conceptions of drinking problems. Journal of Studies on Alcohol, 43, 96109. Parker, D.A., Kaelber, C , Harford, T . C , and Brody, J.A. (1983). Alcohol problems among employed men and women in metropolitan Detroit. Journal of Studies on Alcohol, 44, 1026-1039. Shore, E.R. (1985a). Alcohol consumption rates among managers and professionals. Journal of Studies on Alcohol, 46, 153-156. Shore, E.R. (1985b). Knowledge of alcohol effects among women and men employed in business and professional occupations. Addictive Behaviors, 10, 109-112. Shore, E.R., (1985c). Norms regarding drinking behavior in the business environment. Journal of Social Psychology, 125, 735-741. Smith, T. (1981). Alcohol use during pregnancy. Summit, NJ: American Council on Science and Health. Straus, R., and Bacon, S.D. (1953). Drinking in college. New Haven, CT: Yale University Press. Wechsler, H. (1978). Introduction: Summary of the literature. In Alcoholism and alcohol abuse among women: Research issues (Research Monograph No. 1, DHEW Publication No. [ADM] 80-835). Washington, DC: National Institute on Alcohol Abuse and Alcoholism. Whitehead, P.C., and Ferrence, R.G. (1977). Liberated drinking: New hazard for women. Addictions, 24, 36-53. Wilsnack, R.W., and Cheloha, R. (1987). Women's roles and problem drinking across the lifespan. Social Problems, 34, 231-248. Wilsnack, S.C. (1976). The impact of sex roles on women's alcohol use and abuse. In M. Greenblatt and M.A. Schuckit (Eds.), Alcohol problems in women and children. New York: Grune and Stratton.

9 THE EXTENT AND PATTERNING OF JOB-RELATED DRINKING PROBLEMS HAROLD A. MULFORD

INTRODUCTION A job-based intervention program for problem drinker employees, called "constructive confrontation," was first formalized by Harrison Trice (1962). The program, since described in numerous publications (e.g., Trice and Roman, 1972; Beyer and Trice, 1982), is designed to achieve early intervention, to overcome problem drinkers' denial, to motivate drinkers to change their behavior, to get them into treatment when it is needed, to facilitate reentry into normal roles, and to provide extended social support (Beyer and Trice, 1982). The program "attempted to minimize the need for treatment outside the workplace by maximizing opportunities in the structure of work organizations for early identification, confrontation and behavioral change" (Roman, 1981, 247). In the early 1970s, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) medicalized the constructive confrontation approach, originally founded on social control principles (Roman, 1980), and the programs came to be known as employee assistance programs (EAPs). Although EAPs retained the principle of early intervention based on deteriorated job performance and also the constructive confrontation principle, the new orientation broadened the target population to include all troubled employees, and it emphasized referral to medical experts for diagnosis and treatment, mostly outside the workplace. Despite precious little scientific support (Fillmore, 1984), EAPs were successfully promoted as ideal programs for the early intervention and treatment of alcoholism. Even today, little is known for certain about (1) the prevalence and distribution of alcoholics in the workplace, (2) how well alcoholics fit the medical model, or (3) the outcome of EAP programs (Fillmore and Caetano, 1982; Beyer and Trice, 1982).

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This chapter brings data to bear on two basic EAP assumptions: (1) the bulk of all alcoholics are on someone's payroll and (2) the alcoholic's job is one of the first life areas to be affected by alcohol abuse. The analysis strategy is to (1) identify all of the persons in a general population sample who are problem drinkers, (2) isolate those problem drinkers who are employed, and (3) so far as our limited indicators allow, identify the employed problem drinkers who are experiencing alcohol-related job problems. In addition, we will bring certain data from a clinic sample to bear on the sequential order of job problems and drinking-related problems in other life areas. The chapter concludes with some speculation on the relative merits of programs directed toward alcoholic employees which are based on the medical model versus programs generated by a social network way of thinking. METHODS Data Sets Three data sets are analyzed. The first set was obtained from a cross-sectional general population survey conducted in 1979. The data were collected by faceto-face interviews with a probability sample of respondents representing the adult population of Iowa, age 18 years and older (n = 1,535). The methods have been detailed elsewhere (Fitzgerald and Mulford, 1981). The second data set was collected later, in 1985, in another Iowa survey that essentially replicated the 1979 survey, except that the sample size (n — 1,007) was smaller, and fewer measures were obtained. (For method details, see Fitzgerald and Mulford, 1987.) The third data set comes from a tkcatch as catch can" sample of 572 alcoholics, out of more than 1,000 clients and patients, who came to Iowa's community alcoholism centers between 1966 and 1969. They were interviewed by a clinic staff member using a standard interview schedule which asked the person to recall the year in which various deviant drinking behaviors began. Identifying Problem Drinkers The Iowa Alcoholic Stages Index (ASI) (Mulford, 1977) isolates the problem drinkers in the sample. The index, developed with data from general population samples, measures advancement in the dynamic social interaction process that results in some drinkers' becoming labeled alcoholic (Mulford, 1984; Rudy, 1986). It casts a broad net not unlike D. Cahalan's (1970) problem drinker index, with which it shares much content. A problem drinker is operationally defined as anyone who qualified on at least one of the four component subscales of the index. The qualifying criteria for each subscale of the index, shown in Table 9-1, are a yes response to two or more of the trouble items, a yes response to three or more of the personal effects drinking items, a frequently or sometimes

Table 9-1 Subscales of the Iowa Alcoholic Stages Index A TROUBLE DUE TO DRINKING SCALE (Qualifying score = 2 or more "yes" responses) 1. 2. 3. 4. 5. 6. 7. 8.

Yes No

9. 10.

DURING PAST 12 MONTHS: Has your employer fired or threatened to fire you because of your drinking? Has your spouse left or threatened to leave you because of your drinking? Has a family member complained you spend too much money on alcohol? Have you been picked up by the police because of your drinking? Has a physician told you drinking was injuring your health? Have you had any illness due to drinking Have you had difficulty meeting bills because too much money was spent on liquor? Have you quit or changed jobs because you were in trouble or likely to get into difficulty due to drinking? Have you had any accidents or injuries due to drinking? Have you failed to do some of the things you should - keeping appointments, getting things done around the house or attending to your job - because of drinking? B PERSONAL EFFECTS DRINKING SCALE (Qualifying score = 3 or more "yes" responses)

1. 2. 3. 4. 5. 6.

Yes No

WOULD YOU SAY THESE THINGS ABOUT YOUR DRINKING: Drinking helps me forget I am not the kind of person I really want to be. Drinking helps me get along better with other people. Drinking helps me feel more satisfied with myself. Drinking gives me more confidence in myself. Drinking helps me overcome shyness. Drinking makes me less self-conscious.

Table 9-1 (continued)

C PREOCCUPIED DRINKING SCALE (Qualifying score = 3 or more positive responses)

1. 2. 3. 4. 5. 6. 7. 8. 9.

Freq- Someuently times

Never

I stay intoxicated for several days at a time. I worry about not being able to get a drink when I need one. I sneak drinks when no one is looking. Once I start drinking, it is difficult for me to stop before I become completely intoxicated I get intoxicated on work days. I take a drink the first thing when I get up in the morning. I awaken the next day not being able to remember some of the things I had done while I was drinking. I take a few quick ones before going to a party to make sure I have enough. I neglect my regular meals when I am drinking.

D UNCONTROLLED DRINKING SCALE (Qualifying Score = "Frequently" response to either item) 1. 2.

Without realizing it, I end up drinking more than I had planned to. Item "4" of Preoccupied Scale above.

Job-Related Drinking Problems

129

response to at least three of the extreme deviant (preoccupied) drinking behavior items, and a frequently response to either one of the uncontrolled drinking items. The number of the four subscales on which one qualifies indicates the person's advancement in the alcoholic process; a score of four indicates the most advanced. Employment Status Employed subjects are those who reported being employed either full or part time. The unemployed is the residual category which contains all others, including unemployed persons who are still in the labor market (9 percent of 77), retired people and students who are not in the market (40 percent), housewives with no paid job (23 percent), and the self-employed (27 percent). Job-based Drinking Problems A problem drinker, whether identified by the stages index or by some other such index, does not necessarily exhibit deteriorated job performance, and impaired job performance does not necessarily elicit employer reactions. Table 9-2 lists the available indicators of a drinking-related job problem. Unfortunately, because the study was not designed for this purpose, subjects were not asked direct questions about job impairment caused by their drinking. FINDINGS 1979 Survey Problem Drinker Prevalence and Stage in the Alcoholic Process. A total of 158 subjects in the 1979 general population sample qualified on one or more of the four subscales of the Iowa Alcoholic Stages Index (Table 9-3). This translates into a problem drinker prevalence rate for Iowa adults of 11.2 percent (excluding missing data). The reliability of this rate is evidenced by its virtual replication (11.8 percent) in the subsequent 1985 study. Table 9-3 also shows that only about half of the 158 broadly defined problem drinkers are on someone's payroll. Most (76.5 percent) of them were employed full time. Results indicated that, on most characteristics, the employed and unemployed problem drinkers looked much alike. For example, most were white (100 percent versus 99 percent) and male (70 percent versus 61 percent). Most lived in cities with populations of 2,500 or more (70 percent versus 59 percent), about onehalf had completed high school (44 percent versus 51 percent), and most had household annual incomes of $10,000 or more (84 percent versus 71 percent). We also see (Table 9-3) that more than three-fourths (78 percent) of the 158 problem drinkers were early-stage alcoholics and that the employed and the unemployed are similarly distributed by stage in the alcoholic process.

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Social and Organizational Contexts

Table 9-2 Job-Based Problem Drinking among Employed Problem Drinkers, General Population, Iowa, 1979 (N = 81) INDICATOR

PERCENT

" I N THE PAST 12 MONTHS, HAS AN EMPLOYER FIRED YOU OR THREATENED TO FIRE YOU I F YOU DID NOT CUT DOWN OR QUIT DRINKING?" " I N THE PAST 12 MONTHS, HAVE YOU QUIT A JOB OR CHANGED JOBS BECAUSE YOU WERE IN TROUBLE OR LIKELY TO GET INTO DIFFICULTY DUE TO YOUR DRINKING?" " I TAKE A DRINK THE FIRST THING WHEN I GET UP IN THE MORNING."

0.0%

1.2

"FREQUENTLY"

0.0

"SOMETIMES"

3.7

"I STAY INTOXICATED FOR SEVERAL DAYS AT A TIME." "FREQUENTLY"

0.0

"SOMETIMES"

2.5

"WHO [IF ANYONE] HAS BEEN MOST CRITICAL OF YOUR DRINKING?" (PROEE FOR MORE THAN ONE) REPORTED EMPLOYER CRITICAL OF DRINKING

0.0

ONE OR MORE OF THE ABOVE FIVE ITEMS.

4.9

"I GET INTOXICATED ON WORK DAYS." "FREQUENTLY"

0.0

"SOMETIMES"

29.6

Most (63 percent) of the early-stage problem drinkers were so identified simply by having qualified on the personal-effects-drinking subscale; they merely defined alcohol for its personal effects. But they did not qualify on the trouble-due-todrinking, the preoccupied-drinking, or the uncontrolled-drinking subscales of the index. By contrast, and not surprisingly, we have found that around threefourths of the cases admitted to Iowa's alcoholism clinics are advanced cases, stage score 3 or 4 (Mulford, 1980, 1985). Conceivably, some of the unemployed problem drinkers at large are selfemployed or otherwise fall into the unemployed category precisely because of a drinking problem on their last job. That such was not the case, however, is evidenced by the finding that only one of the 77 unemployed reported being fired during the past 12 months, and another one had quit a job to avoid possible trouble because of drinking. None of the unemployed reported an employer as

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131

Table 9-3 Employed and Unemployed Problem Drinkers by Alcoholic Stages Index Scores, General Population, Iowa, 1979 PROBLEM DRINKERS STAGES

N

%

N

%

UNEMPLOYED N X

TOTALS

INDEX SCORE

EMPLOYED

1

EARLY

123

78

62

11

61

79

2

MIDDLE

28

18

15

19

13

17

3

LATE

6

4

3

4

3

4

4

VERY LATE

1

0.6

1

1

0

0

100X*

77

100X

TOTAL

158

100%*

81

* Due t o rounding, t o t a l s do not add up to 100 percent. being among those most critical of their drinking. Furthermore, only two of them reported drinking sometimes in the morning, and two sometimes went on benders, both types of drinking behavior that could potentially lead to job problems. Drinking-Related Job Problems. Job-related drinking problems appear to be .rare among Iowa's employed problem drinkers (Table 9-2). None of them reported being fired, or even threatened with dismissal, by their employer because of drinking during the past year. Only one reported quitting a job to avoid a possible drinking-related problem with his employer. Considering that only four of the employed problem drinkers are advanced cases, ASI score 3 or 4 (Table 9-3), perhaps we should not have expected many of the employed problem drinkers to have experienced such extreme employment difficulties as being dismissed or threatened with dismissal from their jobs. Still, no one mentioned their employer as being among those most critical of their drinking, even though the interviewer probed for more than one. This is despite the fact that 28 percent of the employed problem drinkers reported others as having criticized their drinking behavior. Furthermore, two other, more indirect, indicators of drinking behavior that might affect job performance likewise identified few cases. Only three of the employed problem drinkers said that they sometimes drink in the morning and only two sometimes go on benders. Overall, only four (4.9 percent) of the 81 problem drinkers reported any of the first five job problem indicators in Table 9-3. Less than 1 percent (0.6 percent) of all 642 employed persons in the sample qualified on the ASI as problem drinkers and also had a job-based drinking problem.

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Social and Organizational Contexts

Another indirect indicator of potential drinking-related job problems, "I get intoxicated on work days," is presented separately in Table 9-2 because the 29.6 percent who said they sometimes do so is exceptionally high. The apparent inconsistency between the responses to this item and all of the other findings suggests that the question may be fraught with ambiguity. Does a positive answer necessarily mean that they were drunk when they should have been working, or were some respondents referring to work days when they got drunk after work, perhaps mostly on Friday nights? 1985 Survey The 1979 survey findings were generally replicated in the 1985 survey. As mentioned earlier, the overall problem drinker prevalence rate was essentially replicated, as were the responses to the job problem indicators shown in Table 9-2. Whatever the indicators are measuring, they seem to be doing so reliably. Unfortunately, the 1985 survey did not obtain employment status, and this precludes further comparisons with the 1979 findings. Clinic Study: The Sequential Order of Job-based Problems Evidence of the place of job-based problems in the sequence of drinkingrelated problems comes from the sample of 572 clinic alcoholics who, when interviewed at intake, reported the year of onset of each of the extremely deviant drinking behaviors listed in Table 9-4. Had the study been designed for the present purposes, we would have inquired about the time of the first occurrence of family and other specific problems. Here, however, we only have evidence that the drinking of these clinic alcoholics had been quite deviant for some years before the occurrence of job problems; such job problems are indicated by the three starred items in Table 9-4: benders, morning drinking, and getting intoxicated on work days. IMPLICATIONS, DISCUSSION, AND RECOMMENDATIONS Implications The data from this study show that (1) only one-half of Iowa's problem drinkers at large are on someone's payroll; (2) none of them reported being either fired or threatened with dismissal, none reported that their employer had been critical of their drinking, and only one quit a job because of drinking; and (3) drinkingrelated job problems, when they did occur, appeared relatively late in the alcoholic process as compared with the appearance of problems in other life areas. These findings lend little support to either of the two basic EAP assumptions addressed: fewer problem drinkers at large are on someone's payroll than is

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133

Table 9-4 Years Since First Occurrence of Selected Deviant Drinking Behaviors, Clinic Alcoholics, Iowa, 1966-1969 (N = 572) AVERAGE YEARS SINCE ONSET 1.

DON'T NURSE DRINKS

2.

DRINK FOR THE EFFECT

3.

DRINK BEFORE PARTY

8.3

4.

DIFFICULT TO STOP

8.2

5.

(GULPING DRINKS)

10.9 10.2

*STAY INTOXICATED FOR SEVERAL DAYS

(BENDERS)

7.1

6.

NEGLECT REGULAR MEALS

6.8

7.

SNEAK DRINKS

6.7

8.

UNABLE TO REMEMBER

9.

WORRY ABOUT NOT BEING ABLE TO GET A DRINK

(BLACKOUTS)

10.

*GET INTOXICATED ON WORK DAYS

11.

*DRINK FIRST THING IN MORNING

6.5 6.12 6.07

(MORNING DRINKING)

5.6

12.

LIQUOR HAS MORE EFFECT THAN IT USED TO

2.2

13.

LIQUOR HAS LESS EFFECT THAN IT USED TO

1.5

Job-based problem d r i n k i n g

indicator

generally assumed, and job problems appear later in the alcoholic process than assumed. Recommended Research To obtain a more complete picture of the epidemiology of job-based problem drinkers than these limited data provide, we recommend further general population survey studies designed for the purpose. This is not the place to attempt to construct an entire survey interview schedule. Suffice it to recommend that, at minimum, future surveys (1) employ several indicators of job performance impairment, building on the list of signs that emerged from Trice's (1957) study of Alcoholics Anonymous members; (2) obtain the problem drinkers' perception of EAP policies, procedures, and actual practices in their own workplaces; (3) obtain the problem drinkers' perception of how drinking in general affects job

134

Social and Organizational Contexts

performance and how their own drinking has affected, or might affect, their own job performance—the possibility that some employees, for example, salesmen, might view drinking as improving, more than impairing, their job performance should not be overlooked—and (4) measure employee advancement in the process of becoming labeled alcoholic. Where are they in negotiating the issue with others? Have they been confronted yet by their employer or significant others, in what ways, and with what results? Ideally, although it is difficult to do, the employer side of the employeremployee relationship would also be investigated at the same time. How does the worker's boss define the situation? Here, one might build on the work of S. Warkov, S.D. Bacon, and A.C. Hawkins (1965). The Future of EAPs Although the workplace may be less than ideal as a site for secondary prevention, nonetheless, if half of the problem drinkers are on someone's payroll, we can think of nowhere that they might be more concentrated. Hence, the workplace still has much potential as a site for influencing many alcohol abusers to change their deviant drinking, if only we knew how best to go about it. There is growing scholarly criticism of the efficacy of the medical model as a guide for social reactions to alcohol abusers (e.g., Fingarette, 1988; Peele, 1984; Rudy, 1986) as well as signs of public dissatisfaction. A senior official of the Iowa Business and Industry Association recently told us that there is growing concern among the members of his organization about the exorbitant costs of medical alcoholism treatment for their alcoholic workers and doubts about its effectiveness. Also, the medical director of a major third-party payer informed us that he too doubts the efficacy of the alcoholism disease concept, and he thinks that alcoholics should not be in a hospital, except when they have physical complications. If these are straws in the wind, if enthusiasm for the disease-treatment-cure way of thinking has peaked, it may be only a matter of time until there is a radical shift in public sentiment and political winds, as there was after only a generation of experience with the failed prohibition movement, and for basically the same reasons—the lack of scientific support and, more significant, the undiminished persistence of alcohol problems. It is evident that medicalized EAPs have not solved the alcoholic employee problem, and, barring the discovery of clear-cut evidence that they make any special contribution that is at all commensurate with their excessive cost, time may be running out for the medicalized EAPs. It is not too soon to be thinking about alternatives. Just as the EAPs were not built on scientific knowledge or on demonstrated effectiveness (Beyer and Trice, 1982), so there is no body of scientific knowledge for constructing an alternative. There is little choice but to follow precedent and to argue an alternative on the basis of belief, faith, and selected research findings. We will argue the advantages of a social model, one that makes more sense of

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135

what little we think we know and one that generates action programs that reach far more problem drinkers at far less cost and no less effectively than do programs generated by the medical model. The Medical Model The Appeal of Alcoholism. A major weakness of the medical model for understanding alcohol abuse is that, contrary to popular belief, the medicalization of deviant drinking behavior is not the consequence of medical science having discovered alcoholism, defined it in terms of a biological mechanism that causes deviant drinking behavior, and then demonstrated an effective treatment. Rather, when alcohol, as the explanation for alcohol abuse, lost its public appeal during the 1930s and 1940s, it left a vacuum. People need explanations, and they especially wanted explanations for aberrant behavior. In the absence of a scientific explanation of alcohol abuse, in an age of "medical miracles," the disease concept had great appeal. A major appeal of the alcoholism disease concept is that it appears to relieve everyone of responsibility for causing alcohol abuse. Furthermore, it relieves nearly everyone of responsibility for dealing with abusers. If the abuser has the disease, then nothing, and no one, is responsible— not alcohol, not the individual, not his family or community, and not his employer or his workplace conditions. Given medicine's mechanistic, Cartesian image of humans as little more than mechanical clockwork, alcoholism, and the deviant behavior it supposedly causes, is theoretically the sole responsibility of physicians. It appears so deceptively simple. Just refer the alcohol abuser to the nearest physician for diagnosis and treatment (body repair). The Treatment Industry Becomes a Black Hole. In theory, responsibility is concentrated in medical professionals. In practice, entrepreneurs dominate the scene. Taking advantage of, and deliberately reinforcing, the public illusion that medical science can diagnose and effectively treat alcoholism, entrepreneurs have built a large and growing alcoholism treatment industry that is rapidly developing into a black hole sucking in alcoholics, problem drinkers, potential problem drinkers, children of alcoholics, grandchildren of alcoholics, impaired employees, and so on apparently without end. The Myth of Alcoholism. The closer alcoholism treatment effectiveness is scientifically scrutinized, the stronger grows the negative evidence (Vaillant, 1983; Fingarette, 1988). H. Fingarette makes a convincing case that alcoholism is a myth. It does not exist in objective reality. Instead, it exists in the mind of the observer and not in the body of the observed. The medical diagnosis and treatment of a nonexistent disease entity has to be an illusion (Mulford, 1988). The Illusion of Alcoholism Diagnosis. Alcoholics, however, do exist. They are constantly being created in a never-ending social interaction process (Mulford, 1984; Rudy, 1986). An alcoholic is anyone to whom society has firmly attached the label. An attached label represents the culmination of long years of negotiation, debate, and uncertainty within the drinker's social network (Rudy,

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1986; Sonnenstuhl and Trice, 1987). Alcoholism professionals usually enter the process only when the drinker is at, or near, the end of the process. They merely add the weight of authority and their professional status to the negotiating process (Rudy, 1986). This often, but not always, convinces the drinker to accept the label; in so doing, he or she finally becomes an alcoholic. The professional who merely confirms the alcoholic label receives undeserved credit for having diagnosed alcoholism. The use of some such scientific-appearing clinical diagnostic criteria as the DSM-II1 also adds weight to the labelers' side of the negotiations. It legitimizes the label and officially confirms it. The Illusion of Alcoholism Treatment. Alcoholism treatment is no less an illusion. The experience that passes as alcoholism treatment is merely another force in the complex of multiple social, psychological, and physiological factors that influence drinking behavior. What, if anything, it might contribute to changing some abuser's drinking behavior, sometimes under some conditions, is unknown. That it contributes anything special to rehabilitation is doubtful. That such costly experience is not necessary is certain. This is evidenced by the many alcoholics who change their behavior without benefit of formal treatment (Vaillant, 1983; Fingarette, 1988; Smart, 1975). Also, alcohol abusers were "maturing out" long before alcoholism was invented, and even long before modern medicine was invented. Alternatives Action programs generated by a social network way of thinking about alcoholics generally have little public appeal. They have no glamour. There is no gleaming brick and mortar for the evening TV news camera, or even white coats or high-tech instruments. They do not even cost enough to attract public attention. Nonetheless, their cost effectiveness, as well as the theoretical sense they make, leads us to recommend them. The peer identification and counseling programs that certain labor unions have long operated (Sonnenstuhl and Trice, 1987) are good examples of social control programs, as is the constructive confrontation approach, before it was medicalized. A major advantage of these and other social control model programs is that, instead of relieving others of responsibility and concentrating it in experts, they attempt to engage others in the process of helping problem drinkers rehabilitate themselves. If alcohol abuse is somehow a consequence of years of social interaction, and not a defective machine part, then rehabilitation will likewise be the consequence of social interaction. Another example of a social control model program, one that we have described elsewhere (Mulford, 1988), is a highly cost-efficient, self-help local community effort that we have been monitoring since it was established in Washington County, Iowa, in 1974. A paraprofessional community alcohol coordinator/ counselor was employed to help all alcoholics, including alcoholic workers, to use most effectively existing community services and resources, including em-

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ployers, to rehabilitate themselves and to provide advice (counseling) in the process. Each year the program serves about one-fourth of the county's estimated alcoholic population for an annual unit cost of about $150 per person served. Another example can be found in Hardin County, Iowa. For the past three years, six small companies have been contracting with a paraprofessional counselor to serve their alcoholic employees. Each company prepays the counselor $25 per year, per employee, and the counselor agrees to help all of the company's employees and also to serve members of the employee's family who want help with an alcohol problem. He also assists alcoholics to make maximum use of community resources and counsels them in the process. While both of these programs can boast their share of grateful testimonials, their success has not been systematically evaluated to the extent that other treatments have. J.M. Beyer and H.M. Trice (1982) have critiqued the evaluation studies of the constructive confrontation approach, and they concluded that the results were generally positive, but need verification. One of the studies (Thorpe and Perret, 1959) found that simple confrontation can result in improvement without referral to treatment. Another study (Schramm and DeFillippi, 1975) came to a similar conclusion. As Beyer and Trice note, these findings are consistent with those of G. Edwards et al. (1977): a lengthy and costly alcoholism treatment in a hospital achieved no better outcome than a couple of hours of advice by the same clinical staff. Evidently, threat of job loss should be part of any effort to help alcoholic employees change their drinking behavior. If the social model programs appear to be too simple and unsophisticated, let me emphasize that not only is the price right, but also they carry little risk of doing harm. If, as it appears, the success rate at least equals that of the more glamorous, medically oriented treatments, then the social program's return on the investment of scarce resources is vastly greater. Moreover, since social programs largely rely on society's own natural defenses, they carry little risk of doing harm. Some Philosophical Food (Drink?) for Thought 1. Humans interact with, more than they react to, their environment (in this instance, alcohol) not so much as it, the environment (alcohol) really is, but as they believe it to be. Reality, as known to a society, is created as people talk with each other (symbolic interaction) and form consensus about the nature of objects and their relationships. 2. Alcoholism, as a creation of the symbolic interaction process, has no empirical referent in objective reality. Once the concept became reified, however, the belief that medical science can, and the pretense that medical experts do, diagnose and treat it, naturally followed. 3. The Rene Descartes-Isaac Newton model of the world as a mechanical clockwork has proven very useful to medical science for understanding the human body, including the physiology and pharmacology of alcohol. However, the model has not explained,

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and we believe it cannot explain, the drinking behavior that marks one as an alcoholic. Knowing the effect of alcohol on the liver, for example, useful as such knowledge is, hardly explains drunk driving, the lost weekend, or the three-martini lunch. 4. In order to understand drinking behavior and to cope with alcohol abuse, we need to understand human consciousness and self-awareness. We need to understand how humans make conscious decisions. Their decisions might (or might not) be influenced by a sore liver. But it will not be possible to understand or to predict them until we understand the multitude of other individually weak forces, such as the drinking norms, social sanctions, beliefs, values, hopes, fears, and collective judgments that also influence individual decisions to drink and how much to drink. Such understanding is not likely until we break out of the Cartesian-Newtonian, linear cause, mechanistic paradigm that has so dominated the physical sciences, including medicine, from their beginning and largely dominates the social sciences (Kuhn, 1970; Capra, 1988). 5. Meanwhile, employers who would do something about their alcoholic employees, as well as policymakers who would formulate formal programs to assist them to do something, are advised to abandon the medical model in favor of a social interaction way of thinking about drinking behavior and alcohol abuse. 6. Alcohol abuse is not a technical problem for which there is a technological solution (Schumacher, 1977). It is the kind of problem with which society can only endlessly grapple, trying different approaches and testing them for their effect on the grappling process.

NOTES Support from Grant No. R01-AA-03829 from the National Institute on Alcohol Abuse and Alcoholism is gratefully acknowledged. My thanks to my colleague, Jerry Fitzgerald, for his very able assistance in preparing this work.

REFERENCES Beyer, J.M., and Trice, H.M. (1982). Design and implementation of job-based alcoholism program: Constructive confrontation strategies and how they work. In Occupational alcoholism: A review of research issues (pp. 181-242). (NIAAA Research Monograph No. 8). Washington, DC: Government Printing Office. Cahalan, D. (1970). Problem drinkers, A national survey. San Francisco: Jossey-Bass. Capra, Fritjof. (1988). Uncommon wisdom: Conversations with remarkable people. New York: Bantam Books. Edwards, G., Oxford, J., Egbert, S., Guthrie, S., Hawkins, A., Hensman, C , Mitchesonn, M., Oppenheimer, E., and Taylor, C. (1977). Alcoholism: A controlled trial of "treatment" and 4kadvice.,, Journal of Studies on Alcohol, 38, 10041029. Fillmore, K.M. (1984). Research as a handmaiden of policy: An appraisal of estimates of alcoholism and its cost in the workplace. Journal of Public Health Policy, 5, 40-64. Fillmore, K.M., and Caetano, R. (1982). Epidemiology of occupational alcoholism. In

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Occupational alcoholism: A review of research issues (pp. 21-88). (NIAAA Research Monograph No. 8, Publication |ADM) 82-1184). Washington, DC: U.S. Government Printing Office. Fingarette, H. (1988). Heavy drinking: The myth of alcoholism as a disease. Berkeley: University of California Press. Fitzgerald, J.L., and Mulford, H.A. (1981). The prevalence and extent of drinking in Iowa, 1979. Journal of Studies on Alcohol, 42, 38-47. Fitzgerald, J.L., and Mulford, H.A. (1987). Self-report validity issues. Journal of Studies on Alcohol, 48, 207-211. Kuhn, T.S. (1970). The structure of scientific revolutions. Chicago: University of Chicago Press. Mulford, H.A. (1977). Stages in the alcoholic process: Toward a cumulative, nonsequential index. Journal of Studies on Alcohol, 38, 563-583. Mulford, H.A. (1980). On the validity of the Iowa Alcoholic Stages Index. Journal of Studies on Alcohol, 41, 86-88. Mulford, H.A. (1984). Rethinking the alcohol problem: A natural processes model. Journal of Drug Issues, 14, 31-43. Mulford, H.A. (1985). Symptoms of alcoholism: Clinic alcoholics vs. problem drinkers at large. In Proceedings of the 34th International Conference on Alcoholism and Drug Dependence, Alberta Alcohol and Drug Abuse Commission, Calgary, Canada. Mulford, H.A. (1988, Fall). Enhancing the natural control of drinking behavior: Catching up with common sense. Contemporary Drug Problems. Peele, S. (1984). The cultural context of psychological approach to alcoholism. American Psychologist, 39, 1337-1351. Roman, P.M. (1980). Medicalization and social control in the workplace: Prospects for the 1980's. Journal of Applied Behavioral Science, 16, 407-422. Roman, P.M. (1981). From employee alcoholism to employee assistance. Deemphasis on prevention and alcohol problems in work-based programs. Journal of Studies on Alcohol, 42, 244-272. Rudy, D.R. (1986). Becoming alcoholic: Alcoholics Anonymous and the reality of alcoholism. Carbondale: Southern Illinois University Press. Schramm, C , and DeFillippi, R. (1975). Characteristics of successful alcoholism treatment programs for American workers. British Journal of Addiction, 70, 271-275. Schumacher, E.F. (1977). A guide for the perplexed. New York: Harper and Row. Smart, R.G. (1975). Spontaneous recovery in alcoholics: A review and analysis of the available research. Drug and Alcohol Dependence, 1, 277-285. Sonnenstuhl, W.J., and Trice, H.M. (1987). The social construction of alcohol problems in a union's peer counseling program. Journal of Drug Issues, 17, 223-254. Thorpe, J., and Perret, J. (1959). Problem drinking: A follow-up study. Archives of Industrial Health, 19, 24-32. Trice, H.M. (1957, May). Identifying the problem drinker on the job. Personnel, 33, 527-533. Trice, H.M. (1962). The job behavior of problem drinkers. In D. Pittman and C. Snyder (Eds.), Society, culture and drinking patterns. New York: John Wiley. Trice, H.M., and Roman, P.M. (1972). Spirits and demons at work: Alcohol and other drugs on the job. Ithaca: Cornell University, New York State School of Industrial and Labor Relations.

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Vaillant, G.E. (1983). The natural history of alcoholism: Causes, patterns, and paths to recovery. Cambridge, MA: Harvard University Press. Warkov, S., Bacon, S.D., and Hawkins, A.C. (1965). Social correlates of industrial problem drinking. Quarterly Journal of Studies on Alcohol, 26, 58-71.

PART II EMPLOYEE ASSISTANCE PROGRAMS AND RELATED STRATEGIES: STRUCTURE, DYNAMICS, AND PROBLEMS

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10 EMPLOYEE ASSISTANCE PROGRAMS: UTILIZATION AND REFERRAL DATA, PERFORMANCE MANAGEMENT, AND PREVENTION CONCEPTS TERRY C. BLUM AND NATHAN BENNETT

In addition to family, school, and community efforts, the worksite is emerging as an area in which effective intervention and prevention of alcohol and drug abuse is feasible. While several structural characteristics of the worksite make this possible, the most significant include the definable organizational boundaries, the captive audience of employees, the availability of health care benefits for troubled employees and family members, and the leverage of peers, managers, and unions to motivate employees toward offered services (Blum and Roman, 1989). Employee assistance programs (EAPs) are mechanisms that provide the workplace with systematic means for dealing with personal problems that affect employees' job performance. By personal problems, we refer to the abuse of alcohol and other drugs, psychiatric disorders, marital and family problems, and, to a limited extent, financial and legal difficulties. While employees are typically encouraged to contact the EAP when they feel a need for help, an especially powerful aspect of the EAP is the role it can play as a tool for supervisors who find themselves bearing the burden of an employee's problem (Roman, Blum, and Bennett, 1987). EAPs can be seen as providing secondary prevention in that they represent a set of reactive mechanisms which can be invoked by supervisors, managers, or union representatives to provide an early intervention for behavioral problems resulting in referral to an efficient and effective help source (Roman and Blum, 1988). EAPs can provide primary prevention of negative consequences of alcohol use through various activities at the worksite. The negative consequences that EAPs are potentially effective in addressing include use of machinery or driving after consumption of alcoholic beverages, as well as the effects of a hangover on the operation of equipment and interpersonal relations. These prevention

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efforts can be influential when they are targeted to individuals who are not necessarily heavy drinkers, but could be faced with the negative effects of their consumption when coupled with other activities. In general terms, EAPs are of two types. In an internal program, the organization designates an employee to devote all or some portion of his or her work time to EAP, including, but not necessarily limited to, assessment and referral of employees, program management, supervisory consultation, and training. In the second type, an external program, the organization contracts with an external provider of EAP services, which may range from the provision of an "800" number for employees to call to a permanent contract employee who spends time on-site. This type of EAP often requires a liaison role or someone in the organization who monitors the EAP contract and is a major link between the EAP and the work organization. Whether internally or externally based, the integration of EAPs into the organization is a prerequisite for them to engage adequately in worksite efforts related to prevention of alcohol problems. EAPs provide expert assistance for implementation and consistent administration of workplace alcohol policies, provide alcohol and other drug abuse education, and provide assistance to individuals whose family members may have problems. EAPs can also provide prevention opportunities through their encouragement of family participation when employees are referred to treatment. Future alcohol problems among the children of alcoholics may be prevented through such processes. In addition, EAPs can use their management information systems to target services or prevention activities toward those units that indicate there may be alcohol- or drug-related problems through, for example, a high accident rate or high health care utilization. Furthermore, EAPs that are integrated into an organization's functioning can be part of organizational development efforts, which include a variety of techniques to alter the workplace. The remainder of this chapter addresses the outcomes and core technology of EAPs, the prevalence of EAPs, the utilization of EAPs, and a systems perspective of the integration of EAPs into the human resources management functions of organizations. The chapter concludes with some comments about the current and potential EAP/alcohol problem prevention link.

EAP GOALS AND CORE TECHNOLOGY EAP goals are diverse, primarily because of the varied reasons organizations report to explain their decision to implement, adopt, and maintain an EAP. Generally, EAP goals can be divided into three management-related and three benefit-related types (Blum and Roman, 1989). The management-related goals are to (1) retain employees in whom the company has a considerable investment, (2) aid supervisors who can become overwhelmed with the management of a troubled employee, and (3) provide due process to employees who are displaying impaired performance. The benefit-related goals are to provide (1) a method to

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Figure 10-1 Core Technology and Functions of Employee Assistance Programs

1

control the organization's health care costs by providing cost-effective treatment to employees before their condition deteriorates further, (2) a gatekeeper function to guide employees to appropriate resources in the community, and (3) an additional benefit to the employees. Based on data and observations from a program of research spanning many years, six aspects of an EAP core technology have been identified (Roman and Blum, 1985, 1988). The core technology is defined as the central activities of an organization which the organization attempts to protect from interference by environmental forces (e.g., Thompson, 1967). In other words, the core technology is a set of activities that "the organization has integrated together into a unique input or set of inputs used to produce outputs in a manner that is uniquely efficient and effective" (Roman and Blum, 1985, 9). The six components are not meant to be an exhaustive list of EAP activities, or even a list of common EAP activities. Instead, the core technology represents components that are not found in other workplace programs. The core technology and EAP outcomes are summarized in Figure 10-1. The six components of the EAP core technology are as follows:

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1. Identification of employees' behavioral problems based on job performance issues. These job performance issues might include attendance, productivity, on-the-job drinking, and the ability to get along with co-workers. Additionally, in some jobs, less traditional measures such as demeanor and appearance may be considered. An important aspect of this portion of the core technology is that the focus is on job-based difficulties, an area in which the supervisor is expert, as opposed to a pattern of clinical symptomatology. 2. Provision of expert consultation to supervisors, managers, and union stewards on how to take the appropriate steps in utilizing employee assistance policy and procedures. This aspect of the core technology points to the importance of a readily accessible specialist in EAP who is available to supervisors and managers to ensure that the policy is consistently, appropriately, and effectively administered. 3. Availability and appropriate use of constructive confrontation. Constructive confrontation is a strategy which takes advantage of the work setting to create an episode where an employee is faced simultaneously with his or her documented job performance decrement and the chance for EAP assistance. Appropriate implementation of this procedure raises the bottom to which alcoholic employees must fall before they become aware of the seriousness of their problems. The EAP administrator is available to supervisors to consult with supervisors regarding this process. This provides a potential for intervention for employees whose families have not been able to leverage or motivate the employee adequately toward help. 4. Microlinkages with counseling, treatment, and other community resources. This component, focused on the management of the individual case, involves the efficient use of community resources as soon as possible. The EAP administrator is in a position to assess the employee's needs and to create an appropriate match with an external agency, if appropriate. Once the referral is made, the EAP is available to assist in case management and follow-up. The EAP plays a role in keeping the referral sources accountable in terms of costs and quality assurance for the clients referred to community resources. 5. The creation and maintenance of macrolinkages between the work organization and counseling, treatment, and other community resources. Typically, the workplace has not had a mechanism by which to identify resources that could be used to aid employees. The key to this aspect of the core technology is the establishment of a balance between the needs of the workplace and the needs of the service providers, each in regard to the needs of employee-clients. The balance of quality and accessibility of services, as well as accountability of the referral sources, is part of this component. Through this component the organization is able to ensure its investment in payment or subsidization of treatment costs, by having the EAP monitor outcomes related to health care utilization. 6. The centrality of the employee's alcohol problems as the program focus with the most significant promise for producing recovery and genuine cost savings for the organization in terms of future performance and reduced benefit usage. Through the years, EAPs have certainly broadened the scope of the services they provide. In terms of a core technology, however, EAPs remain the only strategy that has established a record

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of successfully and constructively addressing alcohol problems in the workplace. These include intervention activities with alcoholics and their dependents, as well as prevention of alcohol problems that have deleterious consequences at work. EAP GROWTH AND PREVALENCE As outlined in chapter 1, EAPs developed out of the industrial alcoholism program model supported by a small number of companies prior to the early 1970s and from the efforts of various National Council on Alcoholism (NCA) affiliates (Blum, 1988; Roman, 1988). In addition to the provision of funding by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for the development of workplace programs by external consultants and the influence of third-party insurance coverage and payment for alcoholism treatment, three environmental forces have contributed to the rapid diffusion of the EAP concept (Roman and Blum, 1987). Technological changes in the workplace have heightened the impact that an impaired employee can have on the workplace and the costs of replacing trained labor. Cultural changes in the ways in which alcohol, drug, and other problems are considered and the concomitant increase in available resources to deal with these problems have made treatment for addictive disorders more available and less stigmatizing. Legal changes which have increased employer responsibility for employee behavioral problems have influenced employer support of the EAP concept. Data on the prevalence of EAPs in the private sector have been sporadically compiled through a variety of methodologies. A series of Executive Caravan studies done by the Opinion Research Corporation for the NIAAA found that, in 1972, 25 percent of the Fortune 500 companies had some form of program to provide assistance to employees with drinking problems. In 1974, the percent was 34; in 1976, 50 percent; and, in 1979, 57 percent of employers supported an EAP (Roman, 1979). Although no similar studies have been conducted recently, most estimates would suggest that nearly all of the Fortune 500 companies have some type of program in place now. A 1985 study of 1,358 worksites with at least 50 employees conducted by the Research Triangle Institute for the Department of Health and Human Services found that 24 percent of the worksites offered an EAP (Kiefhaber, 1987). Phone surveys of Georgia adults found that, in 1986, 25 percent of the working respondents had access to an EAP at work; in 1987, 33 percent reported their employer supported an EAP (Blum and Roman, 1989). A survey of work establishments in 1988 revealed that 31 percent of private sector nonagricultural employees worked for organizations that provided some form of EAP (U.S. Department of Labor, Bureau of Labor Statistics, 1989). These surveys found that presence or absence of an EAP is associated with size of the company, measured in terms of the number of employees, as can be seen in Table 10-1. Employees who work in small organizations represent the preponderance of the U.S. workforce, but they are least likely to have access to an EAP.

Table 10-1 Relationship between Company Size and EAP Presence 1986 and 1987 Georgia House old Surveys 1988 Department of Labo Survey % of Employees with Access to an EAP

1986 Georgia Survey N = 524 67.5% Response

% of Employees with Access to an EAP and the % of Worksites Providing an EAP

1987 Georgia Survey N = 527 68.2% Response

1988 Department of Labor Study Employees Worksites N = 84,965,700 N = 4,542,000 Size (Number of Employees)

Size (Number of Employees) < 25

9%

20%

1 -9

4.2%

3.7%

25-100

17%

30%

10 - 49

11.2%

9.7%

101-250

17%

37%

50 - 99

16.6%

15.7%

251-999

47%

52%

100-249

30.7%

29.4%

1000-1999

62%

64%

250 - 499

45.2%

45.3%

2000 or more

56%

59%

500 - 999

54.2%

53.9%

1000 - 4999

71.9%

70.4%

5000 or more

86.8%

83.0%

Total Employees Covered

25%

33%

Total Organizations Covered

NA*

NA

* Not Available

31% 6.5%

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149

UTILIZATION AND REFERRAL PRACTICES The impact of EAPs on alcohol abuse in the workplace can be examined by an analysis of a longitudinal data collection. Data are presented that describe the extent of EAP usage for alcohol and drug problems, demographic characteristics of EAP users for alcohol and drug assistance, the route by which alcohol and drug cases arrive at an EAP, and the job performance one year after EAP usage by employees with alcohol or other drug problems. In 1984 and 1985, a study was conducted to examine the characteristics and correlates of a sample of 439 EAPs based in private sector company locations with at least 500 employees at a given site. Through a census technique, population lists of all EAPs meeting this criterion were constructed for the six states that had the highest level of EAP activity, based on a 1981-1982 study of external program consultants: California, New York. Texas, Michigan, North Carolina, and Minnesota. Data were collected from all of the sites except in New York and Minnesota, where samples of 50 and 80 percent, respectively, were drawn. Data were collected through on-site interviews and mailback questionnaires. Ninety-seven percent of those contacted for inclusion in the study completed interviews. Of the 439 companies, 289 supported an internal EAP. Mailback questionnaires were received from 219 of these 289 companies (76 percent). These responses make up the 1984 data which follows. In 1988, mail questionnaires were sent to all internal EAP administrators who were interviewed in 1984. The panel data represent more than 70 percent of the original EAP sample, not including those lost to followup due to organizational closing, discontinuation of the EAP (a very rare event), or other organizational transformation. The analysis indicates that, on an average, approximately 5 percent of the workforce will access the EAP in a given year. Rates of EAP utilization are higher for women than men, and overall usage rates tend to be lower, on the average, in: 1. Larger as compared to smaller organizations 2. Worksites where there is a union that represents only a minority of employees as compared to organizations that are predominantly unionized or have no union at all 3. The industries of communication, transportation, and utilities as compared to manufacturing or other service industries On an average, 1.5 to 2 percent of the workforce per year will access the EAP for help with their own (as opposed to a family member's) alcohol or drug problem. Some might find these results discouraging, but if the longer range implications of these rates of utilization are considered, the picture is more impressive. In a workforce of 1,000 employees, an annual 2 percent alcohol and drug utilization rate would lead to 20 referrals for alcohol and drug-abuse assistance. After four years, for example, extrapolation of the above figures would indicate that the EAP would have assisted 80 employees (or 8 percent of the

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workforce) with an alcohol or drug problem (it is important to keep recidivism and employee turnover in mind). These estimates concern only employees who are helped with an existing problem, which must be added to the results of educational efforts in which the EAP engages, and also added to help family members receive. A good predictor of the percent of the workforce who used an EAP for an alcohol or drug problem in 1988 is the percent who did so in 1984. There is a relative consistency in overall utilization rates (r = 0.73) and utilization for alcohol and other drug problems (r = 0.81) between 1984 and 1988, despite some significant variations between the overall utilization and alcohol and other drug utilization rates over EAP age cycles, industry, and organizational size. It is encouraging to note that overall, nearly 70 percent of the referrals to an EAP for help with an alcohol problem are reported to be on the job with adequate performance one year after referral. Less than 10 percent are at work with substandard performance, according to reports by the EAP administrators. One further significant finding is that the statistics for 1984 and 1988 are quite similar. In other words, these aspects of the caseload appear to have remained relatively stable across time. These findings represent just two data points, so it is not possible to examine any possible fluctuations that may have occurred during the intervening years, but the consistency in the data collected four years apart is relevant. It is important to note, however, that the question of abstinence as an outcome measure is not studied in our design. Self-reports of sobriety are notoriously unreliable. Thus the measure of success in the above data sets is continuation of employment with acceptable performance. The routes taken by individuals with alcohol and drug problems to arrive at the EAP, compared to those with problems other than alcohol and drugs, are indicated by the results of the 1988 study. For alcohol and drugs, formal supervisory referrals make up a large minority of the caseload. In fact, when combined with informal supervisory nudges, the data indicate that supervisory involvement is present in almost half of the referrals. An additional one-third of the alcohol and drug referrals are reported to be self-referrals, where no outside impetus is reported. By contrast, employees using the EAP for other than alcohol or drug problems access the program on their own more than half of the time; 18 percent and 13 percent represent formal supervisory and informal undocumented supervisory referrals, respectively. Other referral routes for all EAP clients include union, peer, medical department, benefits or safety, and family referrals. In addition some EAPs receive referrals from courts, particularly for drinking-under-the-influence (DUI) cases. While the route of entry to the EAP is likely to be somewhat distorted by the record-keeping procedures or operationalization in the individual EAPs, records indicating documented supervisory referrals are probably accurate reflections of supervisory involvement. The cases of undocumented supervisory or self-referrals are less likely to be accurate descriptions of the dynamics of the referral process. While some EAPs do not necessarily care how a person came to the

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EAP and may even think that self-referral is the most appropriate source vis-avis motivation for change, it is becoming clear that less than full information about job problems can lead to misassessments by the EAP vis-a-vis alcohol or other drug problems. Furthermore, many self-referrals, where alcohol or other drug problems are identified, are not early-stage problems as some of the EAP literature has suggested, but are often the results of employees with very latestage problems referring themselves for help and self-assessing their problems because they are "sick and tired of being sick and tired." These late-stage referrals often come about when others, that is, supervisors or co-workers, will not for various reasons intervene. EAPs do much more than assess and refer clients. Although the number of clients in the EAP caseload is often used to indicate the level of EAP activity, this information by itself can be misleading. For example, the relative proportion of alcohol and other drug cases can decrease, even though the number of individuals with alcohol problems stays constant, if the EAP caseload increases. All problem categories do not represent similar time commitments of the EAP staff, nor do they represent equal impact on the lives of the individuals who have the problems and on the workplace. EAP caseloads are composed of a minority of individuals with alcohol or other drug problems. Even though alcohol and other drug cases form the minority of EAP referrals, these types of problems tend to take more work time to resolve. More than half (54 percent) of the EAP administrators claim that alcohol and other drug problems take much more of their work time than other problems: 28 percent respond that they take somewhat more time, 11 percent respond that they take the same time, 5 percent claim that they take a bit less time, and only 3 percent claim that they take much less time. Many EAPs also monitor the individuals with alcohol or other drug problems for longer periods of time than they do the individuals with other problems. The term "managed care" conjures up many images and opinions. However, it is a term that includes many different strategies of health care cost containment. Formal managed care arrangements can involve a formal role for the EAP, where alcohol problems, drug problems, or mental illness are at issue. Even where there are no formal managed care arrangements, the micro- and macrolinkages that EAPs make with treatment resources, including informal Preferred Provider Organization (PPO) arrangements, clearly can be considered types of managed care. Almost one-third of the organizations in the 1988 sample, representing middle to large size organizational units, have formal arrangements for managed care of alcohol, drug, or mental health care costs. More than 15 percent of the EAPs are used for precertification of alcohol, drug, or mental health insurance usage; 7 percent of the EAPs are used for larger insurance payments for these problems; more than 15 percent of EAPs are recommended for precertification, but there is no financial incentive for the employee to use the EAP rather than go directly to treatment; and, in 61 percent, the EAP has no role in precertification.

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The precertification role of EAPs is associated (0.67) with organizations that have formal managed care for alcohol, drug, or mental health services. Almost three-quarters of the organizations which mandate EAP precertification also have formal managed care; more than one-third of the organizations in which the EAP precertification allows for larger insurance benefits have managed care; one-fifth of the organizations in which EAP is recommended but there is no financial incentive to use it for precertification have managed care; and a little more than one-fifth of those with no EAP involvement in precertification have managed care. Alternatively, more than two-fifths of those with formal managed care arrangements have the EAP involved in mandatory precertification; less than onetenth of those with formal managed care have the EAP involved for a larger insurance coverage; less than one-tenth of those with managed care suggest EAP involvement, but do not financially reward it; finally, more than two-fifths of those with managed care do not include the EAP in precertification. The referral options utilized by managed care arrangements show that organizations with managed care more often (one-half of them as compared to onethird of the organizations without formal managed care arrangements) use inpatient treatment for first-time EAP clients with alcohol and other drug problems than for those who relapse. However, 27 percent of the organizations with managed care arrangements are equally or more likely to refer first-time clients to inpatient treatment, as compared to 38 percent of those without managed care arrangements. If the categories of "equally'' and "more likely" are combined, the difference between both types of arrangements is not significant. Twentythree percent of those organizations with managed care are less likely to refer first-time clients to inpatient treatment, as compared to 29 percent of the nonmanaged care organizations. EAPs use standard 28-day inpatient treatment referrals, on an average, less than one-half the time, with one-tenth of the clients referred to Alcoholics Anonymous (AA), Cocaine Anonymous, or Narcotics Anonymous meetings, and about three-tenths of the clients referred to outpatient settings. Variation, of course, occurs across and within EAPs in the settings that they use for referrals. The EAP choices are partially accounted for by treatment insurance coverage, as well as by clinical and workplace considerations. However, the data indicate that even in organizations where there is insurance coverage for inpatient alcohol and other drug treatment, this is not always used. The same is true for outpatient treatment coverage. Not all clients are referred to outpatient treatment settings even if it is available. EAPs have been performing case management and micro- and macrolinkage functions as part of their core technology. They are limited to some extent by larger organizational factors and often work within the options available. It seems that managed health care is a function that has been practiced in some EAPs, and now that there is a label for it, the structure, process, and outcomes of it must be addressed. However, it is essential that quality assurance be part of the

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picture, particularly in terms of outcomes. EAPs must be involved in aggressive follow-up and aftercare to ensure the recovery of the clients with alcohol and other drug problems and to ensure the organization's investment or subsidization of treatment costs. It seems that most quality assurance is predominantly focused on the short term with intake and utilization review and that relatively little focus is given to longer term outcomes, which could be used to hold the treatment sources more accountable. EAP INTEGRATION The EAPs that are integrated into their host organization's functioning are empowered to deal effectively with alcohol and other drug problems in a costeffective fashion. They are more likely to receive a flow of clients with an appropriate mix of personal problems, including alcohol problems. They are more likely to have the resources to refer clients appropriately to community and treatment resources. They are more likely to be in a position to implement aftercare and follow-up for those who have received alcohol treatment. They are more likely to be in a position to negotiate favorable PPO arrangements and to hold referral sources accountable for quality treatment. They are more likely to be able to influence benefits availability and to influence organizational changes that are conducive to the prevention of alcohol problems and the reduction of the potential negative effects of alcohol abuse in the workplace. The effectiveness of organizational responses to alcohol problems should be considered in a systems perspective of how organizations respond to other personnel issues that influence the performance of employees and the organization as a whole. A model of the personnel/human resource management system along with other organizational subsystems is presented in Figure 10-2 (adapted from Scarpello and Ledvinka, 1988). The human resource management system deals with organizational contingencies that are posed by the employee interface with the organization's core technology and with the contingencies and uncertainties that are imported into the work organization from the organization's external environment. Personal problems of members of the labor force, including alcohol problems, are part of the external environment that impacts the organization. Personal problems among current employees are also a source of potential uncertainty for the organization, the resolution of which includes the personnel/ human resource performance management function. Integrated EAPs are part of the performance management system that could be used to reduce uncertainty. EAPs can, and many do, interface with the benefits function in organizations. There is a possibility for synergy among rational benefit availability, publicity, and administration vis-a-vis alcohol treatment. Companies with EAPs are also likely to have benefits coverage for alcohol problems (Fennell, 1984). EAPs can also be integrated into the labor/employee relations functions of organizations so that questions about whether the EAP is an appropriate resource for a particular employee could be asked at the first step of the disciplinary process. Often the

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Figure 10-2 Personnel/Human Resource System

question arises late in the disciplinary process during an arbitration proceeding in unionized organizations or in a grievance step in nonunionized organizations when the failure of supervision to attempt a referral to the EAP may be used by the employee or the union representative as a potential shield against termination.

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For a referral at this stage, the EAP will be less effective at dealing constructively with the problem than it would have been if the referral had been made earlier in the process. Of essence here is that EAPs that are integrated into the line management function of organizational management, as well as other divisions of the personnel/human resource management function, are more likely to be effective at protecting the organization from negative consequences of personal troubles and to contribute to the effective functioning of the organization. Failure of management to take appropriate action has organizational costs, as well as personal costs of troubled employees and their co-workers, such as misuse of medical benefits or unnecessary use of grievance procedures. Organizations that use their disciplinary and performance appraisal systems to monitor performance and permit the EAP to be structured in a way to interact with these systems are likely to have more empowered EAPs which can deal more effectively with alcohol and other drug problems. From the outset, EAP literature has encouraged organizations to focus on decrements in work performance and constructive confrontation of the troubled employee based on the documentation of a performance problem as the most effective method of addressing employee alcohol problems (Beyer and Trice, 1982; Trice and Roman, 1978; Roman and Blum, 1985). The management of poor performance has, in a more general sense, been a concern of the fields of personnel management and organizational behavior (e.g., Ouchi, 1981; Mitchell and O'Reilly, 1983). This body of literature makes several contributions to the EAP field through its efforts to understand the processes by which a definition of poor performance is developed by an organization and the way in which supervisors decide an unacceptable level of performance has been reached. Certainly, an understanding of these processes is valuable to EAP efforts to involve supervisors in the early identification of alcohol problems in the workplace. In basic terms, poor performance is an undesired deviation from an agreed upon standard. Three factors come to bear on the judgment of performance which can be troublesome (e.g., Dornbusch and Scott, 1975). The first factor is whether it is possible to reach a consensus on what constitutes adequate performance. Certainly this is easier for some positions than others. For example, on an assembly line, the number of parts which meet specifications that are made can be an indicator. Other jobs have less clear standards (i.e., firemen). Second, performance may be variously classified as poor, adequate, or superior based on the point of view of the person performing the classification. Third, the judgment of level of performance adequacy is affected by the means and accuracy with which the performance is measured. The end result is that managers can differ widely in their perceptions of what constitutes "poor performance" (Mitchell and O'Reilly, 1983). A further problem in using poor performance as an identifier of troubled employees is that performance can suffer because of any number of reasons. For

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example, L. Steinmetz (1969) suggested that performance can be affected by (1) managerial and organizational shortcomings (i.e., employees are poorly supervised or have poorly maintained equipment), (2) the employee's own shortcomings (i.e., dissatisfaction, lack of motivation, alcohol troubles), and (3) outside influences (i.e., family problems). Clearly, the proper supervisory response to poor performance caused by inadequate tools would be different than the one expected if the employee's performance decrement was attributed to a lack of motivation. S.G. Green and T.R. Mitchell (1979) found that supervisors grouped causes of poor performance into i\ve clusters: personal role/job role conflict (e.g., family issues), personal pathology (e.g., an alcohol problem), negative work context (e.g., disruptive co-worker influences), low role orientation (e.g., poor motivation), and low job knowledge (e.g., poor training). An important point regarding these findings is that supervisors appear to have a typology of causes to which they attribute poor performance. To summarize, if supervisors differ in their evaluation of poor performance, systematic identification of troubled employees through a focus on poor performance is not possible. If consensus about what constitutes poor performance in a given situation can be reached, then the effectiveness of constructive confrontation would be improved. Additionally, poor performance can be attributed to a number of causes. Managerial responses to poor performance would be expected to vary based on the attribution made by the supervisor to its cause. Certainly, the effectiveness of any effort to improve performance is based on the degree to which the action taken reflects the cause of the problem. An understanding of how supervisors make these attributions would be helpful in understanding supervisory responses to poor performance. For example, if supervisors can be trained to make better attributions about the cause of a problem, then better outcomes could be expected. This point is stressed in the supervisory training component of an EAP. Attribution theory, from the field of social psychology, is concerned with the way in which we explain the behavior of others (e.g., Kelley, 1967, 1972). In the workplace, attribution theory is used to study the way in which supervisors interpret the behavior of their employees (e.g.. Green and Mitchell, 1979; Cardy and Dobbins, 1986). In terms of poor performance, attribution theory suggests that supervisors try to determine whether the performance problem has been caused by task factors, contextual factors, or person factors (i.e., something " i n " the employee). To make this attribution, supervisors use distinctiveness, consistency, and consensus data (Kelley, 1967). In other words, supervisors are said to ask themselves three types of questions (Green and Mitchell, 1979). First, is the employee performing poorly on one task, or at work in general (distinctiveness)? Second, is the employee's behavior similar to that exhibited in other situations (consistency)? Third, is the employee's behavior unlike that exhibited by his or her co-workers (consensus)? The way in which the supervisor answers these questions is said to determine the attribution made for the poor performance. This is a complicated process, and researchers have suggested that supervisors (or whoever is making an attribution) develop shortcuts to speed the process

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along. One shortcut, or schema, was developed by Weiner et al. (1972). In this model, supervisors would be predicted to consider four elements in making attributions: ability, effort, task difficulty, and luck. Attributions, according to the theory, vary on two dimensions: whether the cause of the behavior is internal or external and whether the cause of the behavior is stable or unstable. Supervisory reactions to a subordinate vary, based on where the hypothesized cause of the behavior lies. If the behavior is seen as internally caused, then the focus of intervention would be placed on the employee; if an external attribution is made, the focus would be on the situation. If the supervisor attributes the performance to a stable cause, the supervisor is more likely to take action than if it is attributed to an unstable cause, because unstable causes create uncertainty for the supervisor. A stable cause is also going to continue to exist if nothing is done, whereas the path of least resistance might be taken for an unstable problem, which might go away on its own. The implication of attribution theory for the EAP field is based on the attributions supervisors make about alcoholism and alcohol problems. If supervisors feel that alcoholism is an unstable cause of a performance problem—one that "raises its head" only occasionally—we would expect the supervisor to be reluctant to act. On the other hand, if the supervisor is aware that alcoholism is a progressive disease (stable), then action would be expected. If the supervisor is able to attribute an employee's drinking to external causes (i.e., a family problem), the supervisor is less likely to take action than if he or she feels the problem lies within the individual. It is important to stress that the goal is not to make supervisors diagnosticians of alcohol problems. The point is that we know, based on previous research, that supervisors include a number of nonwork explanations in their consideration of poor performance. In order for EAPs to be accessed, the supervisor needs to feel that some nonwork causes of poor performance, such as alcohol abuse, are stable and internal. Recent research has shown that, although the disease concept of alcoholism (internal, stable cause) is accepted by individuals in the EAP field (Bennett and Kelley, 1987), the general public (from which supervisors are drawn) continues to embrace a variety of somewhat contradictory views (e.g., Caetano, 1987; Blum, Roman, and Bennett, 1989). Furthermore, use of the EAP must be communicated as mandatory in given situations, rather than merely within the supervisor's realm of discretion. The 1988 data indicate that the extensiveness of supervisory training about the EAP is associated with EAP integration into the organization and with the components of the core technology, particularly with the EAP aiding supervisors and managers in dealing with troubled subordinates. The extent to which supervisory training encourages supervisors to consult with the EAP before confronting an employee is also associated with program characteristics. Further evidence of the relationship between supervisory involvement in EAPs and the implementation of the core technology is found in the statistical associations between the job performance identification component of referrals, the integration of the EAP, and the EAP's supervisory consultation role with:

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• The organization's training of first-line supervisors about performance appraisal and disciplinary procedures • The extensiveness of training of supervisors about the EAP • The extent to which supervisors are encouraged to use job performance criteria as a tool in identifying and confronting problem employees • The extent to which supervisory training encourages supervisors to consult the EAP before constructively confronting an employee The extent of supervisory training in our 1984 EAP sample is associated with a greater likelihood that a reason for the continued support of the EAP in 1988 is to reduce alcohol abuse and to reduce drug abuse. We also find these 1988 program goals of reducing drug and alcohol abuse to be related to the greater emphasis put on availability of EAP staff to supervisors for consultation about how to use the EAP policy and procedures to identify and refer a problem employee appropriately. It is important to note that data from a study of 1.981 managers and supervisors in one company (conducted in 1988) indicate the overwhelming preference of supervisors and managers for employees to "self-refer" themselves to the EAP, which really means that they would prefer not to have to perform a formally documented referral. There are downsides to this preference, however. If, following an informal and nondocumented referral, an individual does not admit to having job performance and disciplinary problems and also does not admit to alcohol or drug abuse, it may be difficult for the EAP to perform an adequate assessment or even to have the correct assessment accepted by the client. Without the leverage of the knowledge of impaired performance, appropriate assessment and referral may be more difficult for individuals with alcohol- and other drugrelated problems. In terms of the utilization rates, we find that supervisory training is related to greater rates of utilization and to greater rates of alcohol and drug utilization. These effects are greater for male utilization rates than for female utilization rates, and they are stronger for training which is given to first-line supervisors than that for middle managers. However, data from our survey of supervisors and managers indicate that supportiveness of the EAP by the referring supervisor's own supervisor is extremely predictive of referrals. Top management support is not significantly related to utilization rates. Greater alcohol and drug utilization rates for males are associated with greater supervisory training that includes the use of job performance data to confront individuals with performance problems, with greater supervisory training that encourages the EAP consultation role with supervisors before a confrontation is made, and with the extent to which performance appraisals are used by supervisors in confronting problem employees. Though more weakly associated, the cocaine utilization rate is associated with the use of job performance appraisals to identify EAP candidates, the use of job performance data by supervisors to

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constructively confront employees, and the use of job performance data by the EAP to present to the employee and to assess adequately the employee's problem. The adequacy of first-line supervisory training and training for middle managers is associated with the integration of the EAP into organizational functioning. The improvement of training since 1984 is also associated with greater integration and the implementation of the core technology, which suggests a continual evolution of the implementation of EAPs. There has been much concern in the EAP community about the decline of supervisory training about the EAP. The concern was brought into sharper focus as questions were raised about whether EAPs really provided a core technology that could deal with employee drug problems in addition to alcohol problems and other problems that they have traditionally handled. Part of the concern revolved around the idea that supervisors were the weak link in the EAP concept. However, it should be pointed out that, if supervisors are not held accountable for making appropriate EAP referrals, they will not be any stronger links in a "for-cause" drug-screening program. This is particularly true if harsh treatment rather than constructive assistance results from positive drug screens. It became clear to some of those investigating the EAP concept that some individuals with drug problems may self-refer, and that many of those whom we label self-referrals are really individuals who drag themselves into the EAP after a period of time when it was clear that they were in trouble to the people around them, including their supervisors, who did not intervene. However, it is also clear that alcohol and other drug abuse is fraught with denial by the individuals, their family members, and their co-workers. There are cases in which supervisors and managers will not take the necessary steps to make an EAP referral when it is appropriate to do so. In some instances this occurs because they do not have the knowledge and skills necessary to make a referral. It is quite possible that performance problems, including demeanor and getting along with co-workers in a constructive fashion, will not show up before family problems. However, it is also quite well known that family members can be enablers, and thereby part of the problem, rather than individuals who will intervene and refer the individual to help. It is because so many individuals with problems do not get help from family members that the workplace is an important route to help for so many who fall through the family net. Minimizing enabling behavior by supervisors is critical if this role is to be effective. EAPs AND PREVENTION EAPs that are appropriately integrated into the functioning of their host organizations are particularly likely to be in positions to effect organizational change that would prevent or absorb the negative impacts of alcohol problems. EAPs, in addition to providing constructive intervention for individuals with alcohol problems or with family members who have alcohol problems, can facilitate prevention in several ways.

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In addition to the influence integrated EAPs can have on the personnel policies and practices in organizations, the introduction of an EAP policy can make explicit the work rules related to alcohol consumption. EAPs are also a logical place from which to conduct educational outreach to employees. Since the EAP maintains an ongoing presence at the worksite, programmatic efforts at prevention have built-in continuity to them. Educational efforts can exist independently or be part of a module in broad-based employee training and education programs that are available to or require the participation of employees. Some organizations have included the EAP in prudent health benefit usage or as a referral source for individuals who had particularly high and unexplained patterns of health care utilization, creating opportunities for employee linkage with the EAP. Many EAPs offer stress management opportunities to employees, which in themselves may not have any long-term benefit. However, part of these stress management programs include components on the use of alcohol to cope. Thus the EAP can have impact on those behaviors where escapist drinking is coupled with heavy drinking or negative consequences. Family members can be the target of prevention activities launched by an EAP, including mailings to the employees' homes and the promotion of the use of EAP as a resource to the family members. EAPs can also engage in prevention activities related to organizational change. Prevention and early intervention programs could be tailored through mapping the areas where there are problems such as high worker's compensation claims, or high expenditures for mental health problems, or physical care for conditions associated with untreated alcoholism. Efforts at organizational development have not been pursued in many EAPs; however, these activities have considerable potential for alcohol-problem prevention. Contexts in which reasonable alcoholrelated behavior is encouraged and potentially problematic alcohol-related behavior is discouraged are consistent with the goals of organizational development that include improved effectiveness, efficiency, creativity, and organizational climate. EAPs continue to do what they were envisioned to do and much more. They are progressing through the evolutionary process of adoption, implementation, and integration. When EAPs are appropriately implemented and adequately empowered they provide mechanisms to deal with new issues that organizational environments pose for workplaces and constructively meet a series of contingencies posed by the problems workplaces import from their environments. EAPs can help reduce the impacts of organizational uncertainty related to human resource problems by forecasting changes, by preventing problems, or by absorbing negative consequences of events. EAPs can gather information that will enable them to engage in constructive organizational development and change planning and practices. This can occur through the appropriate scanning of environmental trends, appropriate utilization of human resource information systems, and knowledge of trouble spots in the organization. When prior information is not available or prevention has not been thoroughly achieved, EAPs can absorb some of the negative consequences of troublesome events by inter-

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vening with individuals who have problems that are or may become organizational or societal problems. By absorbing the negative consequences of events, EAPs can help contain the problem and keep it from escalating. They also contribute to an organizational climate where attitudes and norms related to drinking and drugs are changed, and behavior stemming from problem drinking is not tolerated. They do this in an atmosphere of corporate social responsibility (Blum and Roman, 1989), offering constructive solutions to employee problems through the provision of a relatively low-cost employee benefit. NOTE Support from NIAAA Grants R01-AA-07192, ROl-AA-07250, and ROl-AA-07218 is gratefully acknowledged.

REFERENCES Bennett, N., and Kelley L.S. (1987). Assessing the acceptance of the disease concept of alcoholism among EAP practioners. The Journal of Drug Issues, 17, 219-222. Beyer, J.M., and Trice, H.M. (1982). Design and implementation of job based alcoholism programs: Constructive confrontation strategies and how they work. In Occupational alcoholism: A review of research issues (NIAAA Research Monograph No. 8, pp. 181-242). Washington, DC: U.S. Government Printing Office. Blum, T.C. (1988). New occupations and the division of labor in workplace alcoholism programming. In M. Galanter (Ed.), Recent developments in alcoholism (Vol.6). New York: Plenum Press. Blum, T . C and Roman, P.M. (1989). Employee assistance programs and human resource management. In K.M. Rowland and G.R.Ferris (Eds.), Research in personnel and human resource management (pp. 251-312). Greenwich, CT: JAI Press. Blum, T . C , Roman, P.M., and Bennett. N. (1989). Public images of alcohol: Data from a Georgia Survey. Journal of Studies on Alcohol, 50. 5-14. Caetano, R. (1987). Public opinions about alcoholism and its treatment. Journal of Studies on Alcohol, 48, 153-160. Cardy, R.L., and Dobbins, G.H. (1986). Affect and appraisal accuracy: Liking as an integral dimension in evaluating performance. Journal of Applied Psychology, 71, 672-678. Dornbusch, S.M., and Scott, W.R. (1975). Evaluation and the exercise of authority. San Francisco: Jossey-Bass. Fennell, M.L. (1984). Synergy, influence, and information in the adoption of administrative innovations. Academy of Management Journal, 27, 113-129. Green, S.G., and Mitchell, T.R. (1979). Attributional processes of leaders in leadermember interactions. Organizational Behavior and Human Performance, 23, 429458. Kelley, H. (1967). Attribution theory in social psychology. In D. Levine (Ed.), Nebraska Symposium on Motivation, (Vol. 15, pp. 192-238). Lincoln: University of Nebraska Press. Kelley, H. (1972). Attribution in social interaction. In E. Jones, D. Kanouse, H. Kelley,

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R. Nisbett, S. Valins, and B. Weiner (Eds.), Attribution: Perceiving the causes of behavior. Morristown, NJ: General Learning Press. Kiefhaber, A. (1987). The national survey of worksite health promotion activities. Washington, DC: Office of Health Promotion and Disease Prevention, U.S. Department of Health and Human Services. Mitchell, T.R, and O'Reilly, C.A. (1983). Managing poor performance and productivity in organizations. Research in Personnel and Human Resources Management, 1, 201-234. Ouchi, W. (1981). Theory!. Reading, MA: Addison-Wesley. Roman, P.M. (1979). The emphasis on alcoholism in employee assistance programs: New perspectives on an unfinished debate. Labor Management Journal on Alcoholism, 9, 186-191. Roman, P.M. (1988). Growth and transformation in workplace alcoholism programming. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6). New York: Plenum Press. Roman, P.M., and Blum. T.C. (1985). The core technology of employee assistance programs. Almacan, 15, 8-19. Roman, P.M., and Blum, T.C. (1987). Notes on the new epidemiology of alcoholism in the U.S.A. Journal of Drug Issues, 17 (4). 321-332. Roman, P.M., and Blum, T.C. (1988a). Formal intervention in employee health: Comparisons of the nature and structure of employee assistance programs and health promotion programs. Social Science and Medicine, 26 (5). 503-514. Roman, P.M., and Blum T.C. (1988b). The core technology of employee assistance programs: A re affirm at ion. Almacan, 18, 17-21. Roman, P.M., Blum. T . C and Bennett. N. (1987). Educating organizational consumers about employee assistance programs. Public Personnel Management, 16 (4), 299312. Scarpello, V., and Ledvinka, J. (1988). Personnel/human resources management: Environments and functions. Boston: PWS-Kent. Steinmetz, L. (1969). Managing the marginal and unsatisfactory worker. Reading, MA: Addison-Wesley. Thompson, J.D. (1967). Organizations in action. New York: McGraw-Hill. Trice, H.M., and Roman. P.M. (1978). Spirits and demons at work: Alcohol and other drugs on the job (2nd ed.). Ithaca, NY: ILR Press. U.S. Department of Labor, Bureau of Labor Statistics. (1989). (USDL 89-7). Washington, DC. Weiner, B., Frieze, I., Kukla, A., Reed. L., Nest, S.. and Rosenbaum, R. (1972). Perceiving the causes of success and failure. In E. Jones. D. Kanouse, H. Kelley, R. Nisbett, S. Valins, and B. Weiner (Eds.), Attribution: Perceiving the causes of behavior. Morristown, NJ: General Learning Press.

11 HEALTH PROMOTION PROGRAMS AND THE PREVENTION OF ALCOHOL ABUSE: FORGING A LINK MARTIN SHAIN

Health promotion programs (HPPs) invaded the workplace in large numbers during the 1980s (Danielson and Danielson, 1980; Davis et al., 1984; Dean, Reid, and Gzowski, 1984; Fielding and Breslow, 1983; Forouzesh and Ratzker, 1984-1985; Iverson et al., 1985; Ministry of Tourism and Recreation, 1988; National Survey of Wellness Programs, 1987; Roman and Blum, 1988; Shain, Suurvali, and Boutilier, 1986). These programs deal with a wide variety of health practices and conditions at numerous levels of intensity (Erfurt et al., 1988; Shain, Suurvali, and Boutilier, 1986; Terborg, 1986). Some of the most popular interventions are aimed at stress management (Schwartz, 1982), smoking cessation (Fielding, 1982), weight control and nutrition (Faust and Vilnius, 1983), and fitness and exercise (Cox, Shephard, and Corey, 1981). Indeed, programs in these areas are so commonly found together that P. Roman and T. Blum have referred to them as possible components of an emerging core technology of health promotion analogous in some ways to the key elements that typify fully functioning employee assistance programs (EAPs). Elsewhere, M. Shain (1988) has argued that HPPs, in suitably modified form, might serve as a useful part of a comprehensive strategy aimed at the prevention of alcohol abuse in the workplace. This chapter attempts to advance this argument by referring to certain bodies of empirical data that appear to support it. It is assumed at the outset that researchers and health practitioners in the workplace wish to prevent alcohol abuse and that it can be done. Among the various measures that could be used to prevent alcohol abuse in the workplace, HPPs present themselves as useful candidates for three main reasons. First, they appear to be increasingly abundant. Second, they appear to deal with health concerns that are relevant to alcohol users. Third, they show some promise of being effective when suitably designed and implemented. After

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each of these points has been discussed, the obstacles that might preclude HPP effectiveness, with regard to the prevention of alcohol abuse, are reviewed and proposals to overcome these hurdles are suggested. PREVALENCE OF HPPs Since 1980 at least seven formal surveys have been conducted on HPPs in the workplace (Table 11-1). Since the studies varied enormously in method and scope, comparisons between them are dangerous. However, a comparison is shown here to give readers a notion of scale in relation to four of the five areas noted by Roman and Blum as possible components of an emergent core technology of HPPs. The fifth component, hypertension screening, cannot be directly compared across the studies. It can be seen from Table 11-1 that HPPs relating to smoking cessation, fitness and exercise, weight loss and nutrition, and stress management have been reported most frequently among Fortune 500 companies. R.B. Hollander and J.J. Lengermann (1988) suggest that these companies model innovations for other organizations to which they are later diffused. It appears, in fact, that diffusion within the Fortune 500 group has been rapid since a study conducted two years prior to that of Hollander and Lengermann showed an HPP prevalence rate of only 29.3 percent compared with the 66 percent found by the later investigators (Forouzesh and Ratzker, 1984-1985). The prevalence rate was highest among the top-ranked Fortune 500 companies, that is, among the quintile with the highest dollar-rated sales or services. Of these companies, 91 percent reported having HPPs, with an average number of components of 8.9. This figure dropped to 35 percent among the lowest quintile, where the mean number of components was 5.7. HPPs were most commonly found in printing, mining, office equipment, oil refining, and cosmetics firms (more than 80 percent of the companies) and least commonly in transportation, textiles, and metal products industries (less than 50 percent). Organizational size appeared to be somewhat relevant to whether an HPP of any kind was reported, but it was more relevant to the number of components identified. In both cases, larger organizations outrated smaller ones, though not in a highly significant way. This trend toward the larger organizations offering more programs has been noted in most of the surveys considered here. Although we know very little about the scope, duration, and intensity of the programs offered to their employees by the Fortune 500 companies, it is clear that 75 percent of them engage in some form of smoking cessation and exercise and fitness activities, and over 60 percent provide interventions for weight loss and nutrition and stress management. Hollander and Lengermann are concerned, however, that low participation rates were reported and that such solid planning activities as needs assessment, evaluation, and cost analyses were rarely undertaken. This lack of planning activities suggested to the authors that HPPs had not become fully integrated into the rational planning processes of many of the

Table 11-1 Prevalence of HPP Components in Seven Studies Hollander and Lengermann Fortune 500* (1988)

Roman and Blum 6 States+ (1988)

Shain et al

Fielding & Breslow California + (1983)

Davis et al.

Toronto++ area (1986)

Danielson & Danielson Ontario* (1980)

Colorado ** (1984)

National Survey of Wellness Programs (White) U.S.A. 1987

Smoking Cessation

75%

28%

28%

12%

8%

13%

36%

Fitness/ Exercise

75%

18%

27%

36%

12%

16%

22%

Weight Loss/ Nutrition

65%

23%

9%

18%

13%

13%

15% (Weight Loss) 17% (Nutrition)

Stress Management

61%

48%

31%

15%

13%

15%

27%

*Organizations of all sizes

+0rganizations with > 500 employees

++82% of organizations > 500 employees

•Organizations with > 500 employees

+Organizations with > 100 employees

**97% of organizations with > 100 employees

+0rganizations with > 50 employees

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organizations surveyed, making them vulnerable to budget cuts or other corporate vicissitudes. It was observed, nevertheless, that the firms that did engage in these planning activities were more likely to anticipate expansions of their HPPs in the near future. Pacesetting organizations such as the Fortune 500 group aside, we might expect to find HPPs more frequently in companies where other evidence, such as the presence of EAPs, suggests concern for employee welfare. Two studies have considered the presence of HPPs in the context of existing EAPs. Roman and Blum (1988) examined HPPs among organizations with EAPs and more than 500 employees in six states. They found that just over half of the respondents had an HPP of some sort. Among the components which can be compared across studies it can be seen from Table 11-1 that the most commonly offered program in EAP companies is stress management (48 percent) followed by smoking cessation (28 percent). This situation was also found by M. Shain, H. Suurvali, and M. Boutilier (1986) in a study of Toronto area organizations with EAPs where the corresponding figures were 31 percent for stress management and 28 percent for smoking cessation. At a national level, regardless of whether EAPs are in existence, it has been found in the United States that these two program components are also the most common among a sample of 1,358 organizations with more than 50 employees (National Survey of Wellness Programs, 1987). However, in this survey, smoking cessation programs were found to be somewhat more popular than stress management (36 percent and 27 percent, respectively (see Table 11-1). The ascendance of smoking cessation and stress management programs may be a quite recent phenomenon. Earlier studies, shown in Table 11-1, do not indicate the relative preference for these HPP components. Indeed, in the 1980 study conducted by R. Danielson and K. Danielson in Ontario, Canada, and in the 1983 study conducted by J.E. Fielding and L. Breslow in California, smoking cessation was the least commonly offered intervention; however, in the study conducted by M. Davis et al., in Colorado, there was little difference among the (low) rates at which all four HPP elements were reported. The data referred to in Table 11-1, taken as a whole, suggest that HPPs are a reality in the workplace. Larger organizations and those acknowledged to be in the forefront of their fields tend to exhibit the greatest activity in this area. The presence of HPPs in organizations with EAPs may also be related to size and excellence; the juxtaposition of these two forms of helping program offers the further potential for synergism between them. Given the history of EAPs and their traditional attention to alcohol abuse, it may be that organizations with both EAPs and HPPs will offer the most fertile ground for custom-designed health programs that are more relevant to the needs of employed drinkers. However, Shain, Suurvali, and Boutilier (1986) found that in Toronto the organizations that had both EAPs and HPPs were the least likely to be dealing with alcohol-related cases in their EAP caseloads. This finding may be idiosyncratic to the Toronto area and it should be interpreted in the context of other

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organizational data which indicate that EAPs and HPPs were more commonly found together in corporations in which over one-fourth of the work force was female and which belonged disproportionately to the finance and public administration sectors. The relevance of these observations is that companies of this kind may generate fewer alcohol-related referrals because there are fewer problem drinkers in their work forces. Clearly, though, the alternate possibility should be considered: HPP/EAP organizations currently do not emphasize alcohol problems enough. RELEVANCE OF HPPs TO DRINKERS It would be pleasant though ill-advised to believe that the paucity of alcohol referrals seen in the Toronto study was a result of the preventive impact of HPPs. This is extremely unlikely to be true because of the way in which most HPPs are currently designed and implemented (O'Donnell, 1987), a point that will be considered later in this chapter. Nevertheless, some specific HHPs appear to be relevant to the needs of drinkers, based on the limited data from two empirical studies, although it is evident that the drinkers themselves are generally oriented toward improving their health in ways that could be addressed by suitably designed HPPs. Effect of HPPs on Drinking In two studies conducted by Shain, Suurvali, and Boutilier (1986), it was observed that HPPs of two sorts had reasonably ascertainable effects upon the drinking behavior and supporting health practices beliefs and attitudes of certain participants. In the first of these investigations, at the Champion Spark Plug Company, in Windsor, Ontario, an evaluation was conducted of a Healthy Lifestyles Program called "Take Charge: A Self-Help Course in Feeling Better and Living Longer." The purpose of this six-hour course was to provide employees with a chance to review their lifestyles in relation to cardiovascular health, stress, and the use of alcohol. In this instance, information about alcohol and its relationship with other health practices was woven throughout the sessions on fitness and stress. Although this HPP was pitched at the level of employee knowledge and awareness, the results of a pre- and postmatched questionnaire survey showed that 76.5 percent of the heaviest drinkers among the participants reduced their consumption of alcohol by a mean of 12.3 drinks per week among the males and by 9.0 drinks per week among the females. It should be noted that participation in this course was very high; 56 percent of the work force completed all six sessions. Decreases in consumption were also noted among the more moderate drinkers. These changes were supported by correlated modifications in social drinking attitudes toward drinking and driving, knowledge about problem drinking, and recognition of signs of a personal drinking problem. Although no control or comparison group was used in this study, the correlational

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evidence, supported by pre- and postcourse factor analysis, should be sufficient to at least engage the attention of those who would advance toward more effective high alcohol-content HPPs. In a second quasi-experimental study, the effect of a 15-hour course in relaxation and stress management upon drinking was considered. Here, heavy drinkers maintained their levels of consumption, but significant decreases were observed among male moderate drinkers. In the case of both male and female moderate drinkers decreases in consumption were matched by corresponding, significant reductions in drinking to relieve tension. Furthermore, decreases in drinking were correlated with reductions in levels of distress and anxiety, as well as with reductions in the use of painkillers, changes in eating and working habits, and improvements in sleep patterns. None of these significant changes were observed in a comparison group. Long-term follow-up data were not available, but the short-term effects are encouraging. In any event, it should be anticipated that "boosters" would be required at various points after any such course to reinforce its effects. Drinkers' Concerns about Alcohol Use In the course of conducting a number of health needs/risks assessments in Ontario worksites, the present writer and his colleagues were impressed by the fact that among the population of drinkers a certain proportion showed concern about their alcohol consumption and felt that they should reduce it for health reasons (Shain, 1988). In one worksite, a public transportation company, this group included 11.7 percent of the work force or 17.3 percent of all drinkers. These concerned drinkers, 203 employees in all, manifested concern not only about their alcohol use but also about a variety of other health issues such as exercise, weight loss, nutrition, stress management, and smoking. Furthermore, it appeared that the concerned drinkers had more of these other health concerns than other groups. These points are illustrated in Table 11-2, where alcohol consumption is divided according to whether respondents drank more or less than 21 standard drinks per week, and according to whether they were concerned about it or not. These results are based upon a 90 percent return rate from a questionnaire survey of the work force. Almost identical results have been obtained by the same researchers in other sites. People who are concerned about their alcohol use have more health concerns generally. According to analysis of variance (ANOVA), using the Scheffe Multiple Range Test, concerned heavier users have, on the average, 4.2 other concerns; concerned lighter users have 4.4. These are significantly different, at the 0.05 level, from unconcerned heavier users (2.6), unconcerned lighter users (3.1), and nonusers (3.3). These data suggest very strongly that HPPs are relevant to drinkers at all levels of consumption. These results indicate health promotion "doors" to the alcoholrelated concerns of both heavier and lighter drinkers. Concerned heavier drinkers

Table 11-2 Concern about Drinking and Other Health-Related Concerns* Concerned Drinkers 1 Lower Alcohol Consumption (< 21 drinks per week) n=115 (6.6%)

(n=203) 2 Higher Alcohol Consumption {< 21 drinks per week) n= 88 (5.1%) Other health concerns

Other health concerns Exercise Lose weight Improve eating habits Cope better with stress Check Blood Pressure Reduce smoking Remove stressors Control Blood Pressure

81% 65% 61% 59% 47% 38% 36% 28%

Exercise Reduce Smoking Lose weight Improve eating Cope better with stress Remove stressors Check Blood Pressure Control Blood Pressure

75% 61% 58% 55% 51% 41% 31% 13%

Unconcerned Drinkers (n=968) 3 (< 21 drinks) n=878 (50.6%)

4 0 21 drinks) n= 90 ( 5.2%)

Other health concerns

Other health concerns

Exercise Lose weight Improve eating Cope better Reduce smoking Remove stressors Check Blood Pressure Control Blood Pressure

65% 49% 46% 42% 34% 24% 21% 10%

Exercise Reduce smoking Lose weight Improve eating Check Blood Pressure Remove stressors Seek medical treatment Gain weight

49% 47% 36% 28% 23% 21% 7% 4%

5 Non-Drinkers n=565 (32.5%) Other health concerns Exercise Lose weight Improve eating Cope better Reduce smoking Remove stressors Check Blood Pressure Control Blood Pressure * In a Public workforce)

Transportation

Company

68% 53% 48% 45% 35% 24% 21% 8%

In Ontario,

n=1736 (90% of the

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(more than 21 drinks per week) could be approached through several health promotion doors, namely, exercise, smoking cessation, weight loss and nutrition, stress management, and to a lesser extent blood pressure control. Concerned lighter drinkers could be approached through exercise, weight loss and nutrition, stress management, blood pressure control, and to a lesser extent smoking cessation. The order of priority is different in each case, but no health area seems irrelevant to concerned drinkers, and many seem extremely important. It will not have escaped readers' attention that some of the greatest health concerns of drinkers are resonated in the relative prevalence of HPPs dealing with these concerns, as noted earlier. It would appear, then, that in terms of both primary and secondary prevention of alcohol abuse, HPPs represent open doors to practitioners interested in utilizing them for these purposes. It is worth noting in this regard that health needs/risks assessments of the kind used to generate the data shown in Table 11-2 can also be used to generate information that can be employed to describe the target groups for HPP efforts and for other related interventions. For example, according to the survey data from the public transportation company just discussed, concerned heavier drinkers exhibit the following profile: • • • • • • • •

Well over two-thirds (69 percent) are male, blue-collar workers Over one-third are sometime recreational drug users Nearly one-third use painkillers regularly One-fourth use tranquilizers at least once a month Nearly three-quarters smoke They tend to be overweight and inactive They often get less than six hours of sleep They report being stressed by relations with supervisors and by having every detail of their work controlled by others

In addition, they tend to seek professional help. Eighteen percent of this group were observed to use EAPs, and 25 percent reported using a source of help outside the workplace without going through their employer. This information can be of great value in designing the kinds of HPP that will be most relevant to concerned heavier drinkers. But this raises the broader issue of HPP design, which is currently an obstacle to the use of these programs as doors to alcohol concerns. OBSTACLES IN THE DESIGN AND IMPLEMENTATION OF HPPS Barriers to the Use of HPPs in Alcohol-Abuse Prevention Two barriers lie in the way of those in the workplace who are attracted to the idea of using HPPs as a means of preventing alcohol abuse at either primary or

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secondary levels. The first, already noted, concerns HPP design and implementation; the second concerns the sometimes negative attitudes toward HPPs held by other helping professionals in the workplace, particularly by EAP practitioners.

Overcoming the Barriers Given the variety of interventions described by the term HPP, it is difficult to generalize about their effectiveness. Several reviews have shown, at best, mixed effects in relation to specific HPP components such as exercise, weight loss, stress management, smoking cessation, and hypertension control (Schwartz, 1982; Fielding, 1982; Faust and Vilnius, 1983; Cox, Shephard, and Corey, 1981). Some programs are clearly plagued by low-participation rates, but it is not always clear in relation to what population-in-need or at-risk these rates were estimated (Terborg, 1986). In my opinion, however, participation rates, adherence rates, and effectiveness could all be improved, and program content could be made relevant to employees with alcohol concerns, if the following principles were incorporated into the design and implementation of HPPs. 1. The interrelatedness of health practices, that is, the ways in which they tend to support and maintain each other (Norman, 1986; Shehadeh and Shain, 1988) should be emphasized in all HPPs, whether they deal principally with eating, weight control, smoking, drinking, exercise, stress management, or blood pressure control. 2. Alcohol and drug-specific information should be delivered, and consciousness-raising should be conducted in this context of interrelatedness and interdependence of health practices. 3. Programs should concentrate on helping participants to regain or develop a sense of control, efficacy, and competence in relation to the area in which they choose to begin their way back to wellness (Seeman and Seeman, 1983; Kotarba and Bentley, 1988). This can be accomplished by assisting people to identify realistic personal objectives, and to plan small, incremental steps toward their attainment. 4. Programs should help participants to identify their needs for social support in their efforts to change their health practices (Shain, Suurvali, and Boutilier, 1986; Marcelissen et al., 1988). This includes suggestions about how to solicit support from spouses, family, friends, and fellow workers. It may also include the formation of buddy systems, self-help groups, and links with external helping agencies. Another very significant aspect of social support is the identification of participants' differential needs for expert assistance from HPP leaders and organizers. Some need a lot, some need a little. Attention to the learning preferences of participants in this regard is of great importance to the probability of success. 5. HPPs should take account of the varying literacy levels and cultural backgrounds of actual or potential participants, as these factors bear upon preferences for ways of learning about health and how to improve it. 6. HPPs should be organized around identified time and energy constraints of participants.

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7. They should be sensitive to the fact that some participants may be in the wrong place at the wrong time and may need rerouting to another kind of program. Sometimes this will involve referral to an EAP, either as an alternative or a supplement to the offerings of the HPP. 8. Potential participants in HPPs should be involved in needs/risks assessments through questionnaire or focus group methods. They should, in short, be actively involved in planning the kind of HPP they want. Furthermore, they should be actively involved in monitoring and evaluating the programs. NEGATIVE ATTITUDES OF EAP PRACTITIONERS AND COPING WITH THEM In the Toronto area study, it was found that only one-third of EAP managers believed that HPPs would be of value in the prevention of serious drinking problems (Shain, Suurvali, and Boutilier, 1986). All but one of the companies in which these managers were located had HPPs. Their EAPs tended to have been of recent origin (two years or less) and to have been of the broad-brush variety. Although the case flows through the EAP tended to be high (more than 2 percent per annum), they were also characterized by very low rates of alcohol referrals (often less than 10 percent of the caseload). The same companies tended to have higher proportions of female employees and were more likely to be in the finance or public administration sectors than companies in which the EAP managers perceived no benefit from HPPs in the prevention of alcohol abuse. Furthermore, EAP managers in pro-HPP companies tended to be operating outside the auspices of personnel and medical departments, as separate units (Table 11-3). These data suggest that many EAP practitioners see little value in HPPs as preventive measures with regard to alcohol abuse. Furthermore, those who do see such value tend to come from organizations of certain types, namely those which employ a high proportion of women and which are typically not engaged in manufacturing or trade and commerce. Although there was no direct evidence about the types of professionals involved, it appeared that independence from personnel and medical department auspices raised the odds that EAP practitioners would perceive HPPs as having preventive value with regard to alcohol problems. Stated in their most negative light, these data seem to suggest that EAP managers in male-dominated, production-oriented organizations, where higher proportions of alcohol problems might be expected, were the least likely to endorse the value of HPPs in preventing alcohol abuse. It was not possible in the Toronto area study to determine the professional background of EAP managers to the point that it could be related to attitudes about HPPs. However, anecdotal and circumstantial evidence suggests that those with negative attitudes tended to have dealt traditionally with alcoholics and to believe that prevention of the disease, if it meant anything, could be achieved only by never drinking in the first place or by the total discontinuation of consumption.

Table 11-3 EAP Practitioner Perceptions of Value of HPPs in Prevention of Alcohol Abuse and Characteristics of Their Organizations (all with EAPs), in the Toronto Area Organizational Characteristics (n=45>

Perceived Value

No Perceived Value

Column Percent

1. Age of EAP > 10 years 3 - 9 years < 2 years

11% 35% 46%

89% 65% 54%

31% 45% 24%

46% 50% 27% 28%

54% 50% 73% 72%

29% 18% 24% 29%

14% 50% 46%

86% 50% 54%

40% 28% 31%

70% 30% 27%

30% 70% 73%

28% 28% 43%

50% 14%

50% 86%

28% 72%

44% 26%

56% 74%

55% 45%

47% 11%

53% 89%

78% 22%

2. Sector Government Services Finance/Public Admin. Trade/Commerce Industry/Manufacturing 3. Overall Referral Rate < 1% 2-5% > 5% 4. Percent Alcohol Cases Relative to Total Referrals < 10% 11 - 36% > 36% 5. Percent Workforce Female > 50% < 50% 6. EAP has broadened in scope since inception Yes No 7. EAP is now broad brush Yes No

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174 Table 1 1 - 3 (continued) Organizational Characteristics (n=45)

Perceived Value

No Perceived Value

Column Percent

8. Department responsible for EAP Personnel Medical Other (in or out of house)

21% 31% 61%

79% 69% 39%

42% 29% 29%

63% 27%

37% 73%

24% 76%

9. Agreement with subsidization of HPPs (generally) Yes No

The dispute between EAP and HPP professionals in some ways mimics an earlier and still unresolved debate between those who favor alcohol-focused EAPs and those who favor broad-brush EAPs. The concern of the alcohol-focused practitioners was and is that their tradition of helping alcoholics will be threatened by programs that seem to do too many things, all of them rather badly. Of particular concern is the dilution of the constructive coercion components of traditional alcohol-focused EAPs (Roman, 1981, 1984; Shain, 1984; Trice, 1983; Trice and Beyer, 1984; Trice and Sonnenstuhl, 1987). The fears of these more traditional EAP practitioners appear to have some basis. In advocating the use of HPPs in the prevention of alcohol abuse, it is not my wish to imply that any less attention should be given to the traditional elements of EAP. Indeed, there appears to be a strong argument for reinforcement of the core technology of EAPs at the same time as HPPs are introduced (Roman and Blum, 1985) simply in order to provide a comprehensive response to the needs and risks of all drinkers at all levels of consumption. Additional reasons for resistance to HPPs as preventive measures, however, may be in some degree related to the paucity of documented cases in which such interventions have been shown to be effective. The evidence for EAP effectiveness, on the other hand, is much stronger, even though it is far from satisfactory {Employee Assistance Quarterly, 1988). Thus, it is much easier for EAP managers to argue that scarce human and financial resources should be allocated to their programs rather than to HPPs which, even in less controversial areas, are currently of disputed value. Part of the problem may be lack of top management support for preventive measures which would translate as directives to EAP and HPP professionals to cooperate. This situation shows some signs of changing, as Roman and Blum point out. Pressures on corporations to compete, increasing health care costs,

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and a continuing emphasis on human resource management may conspire to produce the corporate will required to push EAP and HPP practitioners into more coordinated, planned endeavors. In time, this constrained liaison may produce more respectful dialogue between the parties, to the benefit of all employees. Clearly, it is time for EAP and HPP professionals alike to address the needs and concerns of the whole work force, with regard to alcohol use and abuse, in a careful and planned manner, putting aside turf battles and professional animosities in the interests of getting the job done. This, of course, is easier said than done; the problems of coordination are not trivial. It may indeed be necessary to approach the relationship between these groups much as one would approach labor-management relations by attempting, through principled negotiation, to find a community of interests, a common ground, which will unite the parties around a set of shared philosophical premises and practical objectives. One might envision a series of conferences, workshops, and seminars in which this search for a community of interest might be conducted. The theme of such meetings might be organized around an appeal to EAP and HPP practitioners to consider jointly the needs and risks of those employee groups who seem, on the whole, to be missed by workplace programs. Concerned drinkers are a good example of such a neglected target group. They are neither the walking wounded of EAP fame, nor are they the conspicuously well of HPP notoriety. Rather, they are the worried well, the ragged and the frayed, the ones who are struggling to hold on. They get by with very little help from workplace professionals, even though they are often very much in need of it. Community of opinion and interest in relation to concerned drinkers might be hypothesized to exist by asserting, first, the existence of moderately minded people among EAP and HPP professionals (not too hard to show) and, second, the existence among these people of shared beliefs and understandings about the nature of personal unraveling among the ragged and the frayed. These shared beliefs and understandings in reference to alcohol use can be characterized by describing a central position in a continuum ranging from a hypothetically extreme EAP position at one end to an analogous HPP position at the other. It is important to note that these positions are not based upon empirically derived data. They are my projections of hypothesized realities artificially frozen at determinate points on a range. The purpose of describing them at all is to suggest a framework within which common ground can be identified. It is possible that a technique such as focus groups could be used to facilitate this process of identifying clusters of beliefs and understandings. Without the benefit of actually carrying out such an exercise, the projected positions might be imagined as follows. The extreme EAP professional's position with regard to alcohol abuse generally is that it is best considered a disease with a known, progressive pathological career. As such, it is best treated by clinical, medical, and psychiatric methods. Ideally, victims of such disease should desist from drinking altogether if they hope to control the pathological process, just as, if potential victims wish to avoid the pitfall of alcoholism, they should never even begin to drink. Implicit

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within this view is the belief that the pathological process is externally controlled; that is, it is outside the influence of the victim except insofar as that individual can choose to abstain, supported by others who share the same burden and seek the same deliverance from such misery. Within this view, which is reinforced by experience with the walking wounded, the idea of prevention is seen only in terms of lifelong abstinence and avoidance of drinking situations. Consequently, the ragged and the frayed, represented by concerned drinkers, have one of two choices: stop drinking altogether or deteriorate rapidly to the point at which clinical intervention is warranted. In short, EAPs of this hue have little relevance for concerned drinkers, even if they refer themselves, because the response is crisis oriented or treatment oriented. The extreme HPP professional's position is, of course, quite to the contrary. The typical targets of HPPs are people who are motivated to improve their health (even if it is already good) and who, by virtue of their sanguine attitudes, reinforce the beliefs of their course leaders that willpower is all it takes to activate the drive to self-help. Here, there is a belief that most people are inner directed, that they control their own destinies and their own environments. All that is required to catalyze this sense of empowerment is a good dollop of education or consciousness-raising. Accordingly, concerned drinkers would be considered (if at all) as candidates for the receipt of hearty messages affirming their ability to regain control of their lives and knit themselves back together. However, a simple act of will may be a fatuous prescription for the ragged and the frayed, whose needs, it would seem, are as unlikely to be met by HPPs as by EAPs, at least in their extreme versions. Indeed, thus contrasted at their hypothetical extremes, it appears that EAP and HPP professionals have little to say to one another. However, extremes are statistically deviant; many professionals from both areas would exhibit more moderate attitudes and beliefs than those just sketched. In the middle ground, we might expect to find (again, using stereotypes for illustration) a group of EAP and HPP practitioners who, if taken through a clarification exercise, would admit to sharing the following perceptions of concerned drinkers and their needs. 1. They are people whose mental, physical, and spiritual health is imperiled by the slowly incremental adoption of health practices which, if sustained, will cause them permanent harm 2. They are people whose sense of efficacy, control, and competence may have been seriously eroded with regard to their ability to influence their own health by their own actions 3. They are people whose social support systems may have been threatened 4. They are people who may be subject to a variety of environmental stressors which precipitate and sustain their adoption of less than desirable health practices 5. They are people who can help themselves up to a point, but who require training in skills to enable them to regain control of their lives through either HPPs or EAPs

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6. They are people who manifest different preferences for how to learn these skills, that is, from what type of person, in what medium, style, and format, at what rate, and over what period of time These perceptions, if found to be shared, might well form the basis for a joint EAP/HPP strategy for reaching concerned drinkers, that quintessential example of the ragged and the frayed. Such a strategy, in turn, is grist for the mill of researchers who would be called upon to evaluate these joint endeavors in terms of their observed ability to influence drinking behavior and its supporting attitudes and beliefs. With regard to HPPs, which might form part of such a joint strategy, the principles outlined earlier in this argument may serve as guidelines for their design and implementation.

NOTE The author would like to acknowledge the invaluable contributions of the following people to the projects referred to in the text: at the Addiction Research Foundation of Ontario, Bruce Cunningham, Harry Hodgson, and Charles Ponee; and at Health and Welfare Canada, Bob Dooner and Sylvie Bisson. Special thanks are given to Helen Suurvali of the Addiction Research Foundation for her assistance in data preparation and analysis.

REFERENCES Cox, M., Shephard, R.J., and Corey, R. (1981). Influence of an employee fitness programme upon fitness productivity and absenteeism. Ergonomics, 24, 795-806. Danielson, R., and Danielson, K. (1980). Ontario employee programme survey. Toronto, Ontario, Canada: Ministry of Culture and Recreation of Ontario. Davis, M., Rosenberg, K., Iverson, D. et al. (1984.) Worksite health promotion in Colorado. Public Health Reports, 99 (6). 538-543. Dean, P.J., Reid, L., and Gzowski, A. (1984). A planner's guide to fitness in the workplace. Toronto, Ontario, Canada: Ontario Ministry of Tourism and Recreation. Employee Assistance Quarterly. (1988). (Special Issue on Evaluation), 3, 3/4. Erfurt, i.C, Heirich, M.A., Foote, A., and Gregg, W. (1988). Worksite wellness programs—What works and what doesn't work. Ann Arbor: University of Michigan, Worker Health Program, Institute of Labor and Industrial Relations. Faust, H.S., and Vilnius, D. (1983). The Go to Health Project: Summary of findings with emphasis on the relationship between weight and absenteeism. In F. Landry (Ed.), Health risk estimation, risk reduction and health promotion. Proceedings of the 18th Annual Meeting, Society of Prospective Medicine, Quebec City. Canadian Public Health Association, Ottawa. Fielding, J.E. (1982). Effectiveness of employee health improvement programs. Journal of Occupational Medicine, 24 (11), 907-916. Fielding, J.E., and Breslow, L. (1983). Health promotion programs sponsored by California employers. American Journal of Public Health, 73 (5), 538-542.

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Forouzesh, M.R., and Ratzker, L.E. (1984-1985). Health promotion and wellness programs: An insight into the Fortune 500. Health Education, 15, 18-22. Hollander, R.B., and Lengermann, J.J. (1988). Corporate characteristics and worksite health promotion programs: Survey findings from Fortune 500 companies. Social Science and Medicine, 26 (5), 491-501. Iverson, D., Fielding, J., Crow, R., and Christenson, G. (1985). The promotion of physical activity in the U.S. population: Status of programs in medical, worksite, community and school settings. Public Health Reports, 100 (2), 212-224. Kotarba, J.A., andBentley, P. (1988). Workplace wellness participation and the becoming of self. Social Science and Medicine, 26 (5), 551-558. Marcelissen, F.H.G. et al. (1988). Social support and occupational stress: A causal analysis. Social Science and Medicine, 26 (3), 365-373. Ministry of Tourism and Recreation (Ontario). (1988). A guide to planning for fitness in the workplace. Sports and Fitness Branch, Toronto, Ontario, Canada. National Survey of Wellness Programs. Washington, DC: (1987, June). Office of Disease Prevention and Health Promotion. Data reported by Sara White at Beyond EAP, a conference sponsored by the University of California at San Diego. Norman, R. (1986). The nature and correlates of health behavior. (Health Promotion Studies Series No. 2). Health and Welfare Canada. O'Donnell, M.P. (1987). Design of workplace health promotion programs (2d ed.). Birmingham, MI: American Journal of Health Promotion Monograph. Roman, P. (1981). Prevention and health promotion programming for work organizations: Employee assistance program experience. (Prevention Resources Project Monograph). DeKalb: Northern Illinois University. Roman, P. (1984). Jury is still out on EAP—wellness program integration. Employee Health and Fitness, 6 (7). 77-88. quoted on pp. 78. 79. Roman, P., and Blum, T. (1985). The core technology of employee assistance programs. Almacan, 15, 8-19. Roman, P., and Blum, T. (1988). Formal intervention in employee health: Comparisons of the nature and structure of employee assistance programs and health promotion programs. Social Science and Medicine, 26 (5). 503-514. Schwartz, G.E. (1982). Stress management in occupational settings. In R.S. Parkinson and Associates (Eds.), Managing health promotion in the workplace (pp. 233251). Palo Alto, CA: Mayfield Publishing. Seeman, M. And Seeman, T. 1983. Health behaviour and personal autonomy: A longitudinal study of the sense of control in illness. Journal of Health and Social Behavior, 24, 144-160. Shain, M. (1984). An exploration of the ability of broad-based EAPs to generate alcoholrelated referrals. In J.L. Francek, J.H. Klarreich, and C.E. Moore (Eds.), The human resources management handbook: Principles and practice of E.A.P. New York: Praeger. Shain, M. (1988). The heavy drinker in the workplace. A challenge to EAP and health promotion professionals. Almacan, 18 (12), 16-18. Shain, M., Suurvali, H., and Boutilier, M. (1986). Healthier workers: Health promotion and employee assistance programs. Lexington, MA: Lexington Books, D.C. Heath. Shehadeh, V., and Shain, M. (1988). Exploring influences upon wellness in the work-

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place. A multivariate approach. (Manuscript). Toronto: Addiction Research Foundation of Ontario. Strecher V., deVellis B., Becker, M., and Rosenstock, S. (1986). The role of selfefficacy in achieving health behavior change. Health Education Quarterly, 13, 73-91. Terborg, J.R. (1986). Health promotion at the worksite: A research challenge for personnel and human resources management. In K.M. Rowland and G.R. Ferris (Eds.), Research in personnel and human resources management (Vol. 4). Greenwich, CT: JAI Press. Trice, H.M. (1983). Employee assistance programs. Where do we stand in 1983? Journal of Psychiatric Treatment and Evaluation, 5, 521-529. Trice, H.M., and Beyer. J.M. (1984). Employee assistance programs: Blending performance-oriented and humanitarian ideologies to assist emotionally disturbed employees. In J.R. Greenley (Ed.). Research in community and mental health (Vol. 4, pp. 245-297). Greenwich, CT: JAI Press. Trice, H.M., and Sonnenstuhl, W.J. (1987). Organizational and occupational dimensions of EAPs: A review and critique. Ithaca, NY: Cornell University, Department of Organizational Behavior, School of Industrial and Labor Relations.

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12 EXPANDING THE ROLE OF EAPs INTO PRIMARY PREVENTION: THE EAP AS ORGANIZATIONAL CONSULTANT WALTER REICHMAN AND FRANK GUGLIELMO

This chapter suggests the development of a process for the intervention into organizations by employee assistance programs (EAPs) as a method of primary prevention. This process is called for by the coalescing of recent research concerning stress and alcoholism, and the influence of the organization on each. This process requires recognizing that EAP functions include those of an organizational consultant. In conceptualizing the EAP as a reactive intervention in the working lives of organizational employees we sometimes overlook the fact that the EAP exists and functions in the ongoing stream of organizational life. The primary focus of the EAP is, and rightly continues to be, the improvement and correction of job performance decrements through concern with the health and well-being of employees. It no longer seems possible, however, for the EAP to maintain this focus and yet ignore organizational influences over the health and well-being of employees and over the functioning of the EAP itself. Two sets of organizational influences are particularly salient to the EAP. The first is an appreciation for the characteristics of the organization that will affect the implementation of the EAP. The second concerns those characteristics of the organization that may be seen as responsible for decrements in job performance by virtue of their negative influence on the well-being of employees. ORGANIZATIONAL INFLUENCES ON IMPLEMENTING EAP PROGRAMS The effectiveness of the implementation of employee assistance programs within an organization is an important determinant of the eventual success of the EAP. Without adequate implementation, only a paper program, useless

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in achieving either primary or secondary prevention, is possible. Therefore, an understanding of the process of implementing the EAP within the structure of the organization is essential to achieve prevention strategies as well as intervention strategies. However, except for the work of J.M. Beyer and H.M. Trice (1978), the factors that affect the implementation of EAP programs have not been of major concern to researchers. As part of an evaluation project we have been studying the process of implementing an EAP program in the New Jersey State Police. The two stages of designing an intervention, such as an EAP, are the initiation stage and the implementation stage (Zaltman, Duncan, and Holbeck, 1973). The initiation stage includes the design of the intervention, efforts to obtain support, and program development. In the implementation stage, the new program is put into use. Beyer and Trice (1978) in a retrospective study, investigated the implementation of a federally mandated employee alcohol and drug abuse policy. They divided the process into three stages: diffusion, receptivity, and use. Building on Beyer and Trice's retrospective study, we investigated the process prospectively, over a five-year period, as the EAP in the New Jersey State Police unfolded. Our study is not a strict replication of Beyer and Trice's study; we borrowed their three-substage concept and turned their interview protocol into Likert-type questions which were presented to a stratified random sample of police on four occasions. We attempted to determine whether the three implementation substages would follow in sequence. Along the way we rediscovered some elements of EAP implementation that have long been known. Publicity, supervisor training, and continued overt support from the highest echelons are most important for the implementation of the program. These elements are derived from the organization, and thus the EAP must be able to influence the organization in order to elicit these key elements of support. The attitudes of organizational members are another key element which may affect program implementation. These attitudes may have positive or negative influences. In our study, some of the troopers' beliefs about the organization were detrimental to the implementation of the program. Among these attitudes are that supervisors do not know how to confront a subordinate with poor job performance, that job performance cannot be adequately measured, and that supervisors rarely discipline subordinates who exhibit poor job performance. These issues are not EAP issues but organizational issues. These beliefs, which are actually criticisms of the state police department rather than the EAP, have a negative impact on the program. Even though they are outside the normal purview of the program, EAP administrators must address them if their programs are to be successful. We also learned that the New Jersey State troopers had knowledge and beliefs about alcoholism and its effects that should have made the program easier to implement. Among these are that there was a need for the program, that there is an alcoholism problem among the troopers, that alcoholism is a disease, that

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people can change their behavior, and that troopers would accept a recovering alcoholic as a partner. These employee beliefs, which are representative across members of the organization, manifested themselves in the initial development of the EAP. The EAP must now influence the organization to reinforce these positive attitudes. ORGANIZATIONAL INFLUENCES ON EMPLOYEE HEALTH, WELL-BEING, AND STRESS EAP concerns with organizational influences cannot be limited to those that affect program implementation. Of equal concern is the potential negative impact of the organization on employees' health and well-being. An implicit principle of the EAP model is that the EAP handles employees whose job deterioration cannot be explained by conditions of the work (Roman, 1988). This begs the question, "What is the role of the EAP when deterioration can be explained by the conditions of work?" One illustrative case in point is job performance deterioration that stems from stress. In the course of our work with the New Jersey State troopers, we conducted a survey at the EAP administrator's request which asked troopers whether they wanted the EAP staff to conduct training on any of a list of topics. The first choice on the troopers' list was stress management, followed by alcoholism, improving family relations, financial and budget help, and drug abuse. It is obvious that the New Jersey State police are concerned with stress, even more than alcoholism, which ran a close second. It is true that stress and stress management are terms that are exceedingly popular in our contemporary culture. Nevertheless, there is sufficient research evidence to show that stress and stress management should be considered more than just a passing fad (Schuler, 1980). It is also obvious to all that no matter how one defines and measures stress the police are prime candidates for it. Our next step in the New Jersey project is to design and distribute a questionnaire on stress. Although this procedure is still under way, the results can be hypothesized by extrapolating from a study conducted in 1981 by a management consulting firm (Rohrer, Hibler, and Replogle, Inc.) for the New York City Police Department. They found that stress was less a function of the job of policeman than a function of the organization. Interviews with police officers indicated that threats to their person experienced on the street were not as severe a source of stress to them as was the system of control and the discipline practiced by the department. It was not the fact of punishment, nor its severity, but rather the way in which punishment was carried out that acted as a stressor. When officers related stress symptoms (e.g., rage, tension, anxiety, aggression), the symptoms were more related to management practices than to external events. Other stressors experienced by the officers were a sense of being under scrutiny, the continual questioning of their judgment, and the belief that supervisors do not act to reduce the ambiguity of the conflicting demands placed upon them.

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A typical statement reflecting the frustration officers felt with these aspects of the organization was, 4tIt seemed that to do what was asked, one must do something else that was not asked. To obey one rule, one must bend another." When researchers asked command officers in the New York City Police Department what caused stress in their men, they responded (1) lack of role clarity, (2) isolation or lack of support from the formal organization, and (3) management inflexibility. Sergeants, as do many first-line supervisors, see themselves as caught in the middle between management and their subordinates who must carry out the tasks. They also see themselves as having little control over the resources that would enable them to accomplish their tasks. The concept of stress is not well defined, and the types of organizational characteristics and work conditions which have been shown to produce stress are varied (Beehr and Newman, 1978). Some stressors are relatively objective: the physical environment, the pace of work, and whether this pace is set by machine or by the individual. Other causes of stress are subjective and are based on the appraisal of the stressor by the individual. These include many aspects of the role individuals play in organizations, for example, role ambiguity—the extent to which priorities, expectations, and evaluation criteria of the job are clear to the individual; role conflict—the extent to which the individual experiences conflicting role demands and loyalties; and role overload—the extent to which the job demands exceed resources and the individual's abilities to meet the demands (Osipow and Davis, 1988). With respect to organizational-level variables, stress is associated with situations in which high demands are placed on individuals without providing them with a wide latitude of decision-making power or support from the upper levels of the organization (Spector, 1986). For the New York City Police, the job characteristics that were found to lower stress include a clear understanding of what is to be done and sharing this information with others. Naturally, the job of a state trooper is expected to contain a reasonable amount of stress given the dangerous nature of the job tasks. However, the variables noted above as being the causal agents of stress for the troopers are organizational characteristics which can be found in most organizations. R.S. Schuler (1980) contends that stress is a dynamic condition, experienced by the individual, when confronted with either a demand, opportunity, or constraint on being, having, or doing what he or she desires. Organizational characteristics, such as those presented above, can impinge upon individuals in any organizational setting. For the EAP, it is also important to consider the individual's coping capacity. S.H. Osipow and A.S. Davis (1988) have provided evidence that the coping resources the individual brings into a situation serve as moderators of work environment stress. J.C. Latack (1986) defines stress as a dynamic process which includes the environmental stressors, the cognitive appraisal of these stressors by the individual, the level of stress that is experienced, and the coping strategies and resources available to the individual.

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The experience of stress is an interaction between environmental conditions and the characteristics of an individual. What is one person's distress is another's opportunity. A given level of stress may be either performance enhancing or inhibiting depending on the individual's job ability and need for arousal (Schuler, 1980). Over the years the EAP has been concerned with identifying the behaviors of individuals that inhibit job performance and trying to reduce their workplace impact. It may be time to expand the EAP process to include identifying organizational characteristics as well as the interaction between organizational characteristics and individual behavior that may lead to the inhibition of job performance. If we are interested in performance in the organization then we must be aware of the cost of stress. In 1970 the national cost of executive stress in terms of dollar value of days lost was $10 billion. Job stress is so aversive to most employees that they will try to avoid it by withdrawing either psychologically or physically (Bhagat et al., 1985). If we are interested in alcoholism in organizations we cannot ignore stress. Drinking for the relief of stress appears to be an important contributor to increased alcohol use (Nathan et al., 1970). A recent review of research into stress and alcohol by R.J. Powers and I.L. Kutash (1985) has found an inconsistent relationship. Alcohol has been found to relieve stress in some circumstances but not in others. However, whether or not alcohol does, in fact, relieve stress, the expectancy alone may increase alcohol consumption for many people. The intermittent relief from stress that alcohol provides can result in a tenacious pattern of drinking (Powers and Kutash, 1985). D. Parker and G. Farmer (1988) have recently provided evidence that relates drinking behavior to work stress. This points to stress as a particularly germane example of organizational influence that can negatively impact upon an EAP's constituency.

THE EAP IN THE ROLE OF ORGANIZATIONAL CONSULTANT The legitimacy of the EAP's intervention into the organization is provided by P. Roman's (1988) delineation of a seventh dimension of EAP's core technology, consultation with the organization at large. This role involves both reactive and proactive activities as an organizational expert on issues and personal problems affecting employee welfare. If EAP administrators are to function, in part, as organizational consultants, should they not be aware of the conditions of work that lead to poor or deteriorating performance? Further should they not, through the EAP, attempt to impact the organization to ameliorate the conditions of work that lead to poor performance? T.A. Beehr and J.E. Newman (1978) have proposed a process model which strongly suggests that it is in the best interest of the organization to monitor and manage organizational change that is in response to the stressful impact of the

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organization on the individual. In their model, Beehr and Newman describe the individual as making an initial adaptation to job stress. This may take the form of physiological responses, such as elevated blood pressure, or psychological factors, such as impatience or job dissatisfaction. As these initial measures prove dysfunctional and the job-related stress continues, the individual moves into a second attempt at adaptation. This adaptation may be functional, such as clarifying or redefining job roles, or it may be dysfunctional, such as decreased performance, absenteeism, or substance abuse. At this point, Beehr and Newman suggest that the organization, whether aware of it or not, also changes in some ways to adapt to the stress that this individual is experiencing. We suggest here that EAPs have the opportunity to collect information about the various characteristics of individuals and their organizational situations which will be invaluable to manage properly the organization's response to its employee's jobrelated stress. If the EAP does not intervene and the stress remains unchecked, there may result long-term human and organizational impairment. The effects of stress are known to have a ripple effect and impair the associates of the stressed person. An example of the EAPs' acting as an internal consultant was described by M.J. Binet, A.T. Starr, and S. Monaghan (1988) in an organization undergoing a great deal of change. After studying more than 3,000 EAP client records, they concluded that male and female employees of all ages, every job position, and every length of employment experienced negative effects from the changes. The EAP was able to give the organization a snapshot of what employees were experiencing during a time of transition and change. Management began to take corrective action to ameliorate the effects of change in the organization. The position that EAPs should be concerned with and attempt to affect those conditions of work that lead to the deterioration of performance has direct implications for primary and secondary prevention. In the process of providing secondary prevention, that is, assisting poor performers, the EAP must be able and willing to uncover those organizational factors that are causal determinants of poor performance, and it must be willing and able to address these root causes as part of primary prevention. This might entail enlarging the scope of the EAP to include the role of organizational consultant. The technology for implementing organizational interventions has existed in the literature for a number of years. This knowledge is readily available to EAP administrators (Nord and Tucker, 1987). It now needs to be applied to primary prevention programs. The following procedure is a proposal for EAP administrators to begin dealing with performance problems rooted in the organization. An intake instrument needs to be designed that will focus on job activities as well as personal problems. The intake procedure should contain questions concerning:

1. The properties of the work itself—such as complexity, repetitiveness, risks, and autonomy

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2. The characteristics of the work role—such as role ambiguity, role overload, and role conflict 3. Interpersonal relationships—such as the quality of relationships with supervisors and managers 4. Resources and equipment, including human resources—such as the number of employees 5. Work schedule—such as work shifts, day versus night work, and length of work schedule 6. Organizational climate issues—such as management styles (e.g., autocratic) and participation in decision making The EAP should keep records by department and division of the results of the intake procedure. When, based on these data, the EAP administrator becomes convinced that the problems of employees from a particular division are caused by organizational factors, the administrator should bring the information to the attention of the appropriate individuals in the organizational hierarchy. It does not matter whether the EAP is an internal program or stems from an external provider. If it is an external program, there must be a liaison with the organization. This liaison person then becomes the conduit for transmission of information about the organization back to the organization. The EAP administrator (or liaison) must then play the role of internal consultant, taking on the difficult task of initiating change in the organization. At the same time, and continuing until change is accomplished, the EAP must work with the individual to deal with the problems that are organizationally based. Work with the individual should include, at a minimum, an identification of the stressors the employee is experiencing and a strategy for coping with these stressors. Without doubt, the procedure just described is incomplete and inadequate for dealing with the enormously difficult task of initiating change within an organization. It must also be recognized that the majority of EAP administrators are, today, unprepared to function as internal organizational consultants. The EAP administrator must learn to deal with the practical problems of using the power and resources he or she has. The EAP consultant, in common with many internal consultants, lacks awareness of the power resources he or she may possess: expertise, control over information, access to individuals who wield political clout, the respect and positive feelings for the EAP administrator, and the support he or she has from his or her own staff and from other groups working in tandem with the EAP (Pettigrew, 1982). Thus, this proposal is not a prescription for actions to be taken today. Rather, it speaks to long-range goals, to attracting to the field those who are qualified to take on the role of an internal consultant and to providing specialized training to those already in the field. The EAP began as a response to the alcoholism problem. The utility of the program to serve a wider range of employee and organizational needs soon became apparent. The result was an enormous growth in diversity of services.

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Some practitioners and theorists feared and still fear that the alcohol component of EAPs will be lost or overshadowed by other services and the attraction of professionals to the EAP field who have no commitment to alcohol identification and referral. Those who feel very strongly that EAPs should remain primarily substance-abuse based will reject this call for expansion and the attraction of new talents to the field. Although one can understand their loyalty to the base program, it is not possible to restrain the development of a program with the power and potential of the EAP. The substance-abuse component will still remain a major part of the EAP, given the national concern with the problem and the growth of substance-abuse problems in the workplace. We are at a point in our development where we need not fear the introduction of new procedures to help the employee. Employee assistance programs are ready for the next step in what is developing into a rapid evolutionary process. In 1972 there was only a vague plan as the staff of the National Institute on Alcohol Abuse and Alcoholism and their consultants were getting ready to train the first group of federally subsidized occupational alcoholism program consultants at Pinehurst, North Carolina. Just as the procedures of the first 18 years of employee assistance programs gave rise to the research that has prepared us for the future, so too will the procedures of the next evolutionary steps give rise to new research.

REFERENCES Beehr, T.A., and Newman, J.E. (1978). Job stress, employee health, and organizational effectiveness: A facet analysis, model and literature review. Personnel Psychology, 31, 665-697. Beyer, J.M., and Trice, H.M. (1978). Implementing change. New York: Free Press. Bhagat, R.S., McQuaid, S.J.. Lindholm, H., and Segovis, J. (1985). Total life stress: A multi-method validation of the construct and its effects on organizationally valued outcomes and withdrawal behaviors. Journal of Applied Psychology, 70, 202-214. Binet, M.J., Starr, A.T., and Monaghan, S. (1988, November). Organizational changes and their effects on EAP clients. Paper presented at the ALMACA Annual Conference, Los Angeles, CA. Latack, J.C. (1986). Coping with job stress: Measures and future directions for scale development. Journal of Applied Psychology, 71, 377-385. Nathan, P.E., Titler, N.A., Lowenstein, L.M., Solomon, P., and Rossi, A.M. (1970). Behavioral analysis of chronic alcoholism. Archives of General Psychiatry, 22, 419-430. Nord, W.R., and Tucker, S. (1987). Implementing routine and radical innovations. Lexington, MA: Lexington Books. Osipow, S.H., and Davis, A.S. (1988). The relationship of coping resources to occupational stress and strain. Journal of Vocational Behavior, 32, 1-15. Parker, D. and Farmer G. (1988). The epidemiology of alcohol abuse among employed men and women. In M. Galanter (Ed.), Recent developments in alcoholism (pp. 113-130). New York: Plenum Press.

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Pettigrew, A.M. (1982). Towards a political theory of organizational intervention. In M.D. Hakel, M. Sorcher, M. Beer, and J.L. Moses (Eds.), Making it happen: Designing research with implementation in mind (pp. 41-59). Beverly Hills, CA: Sage. Powers, R.J., and Kutash, I.L. (1985). Stress and alcohol. The International Journal of Addictions, 20 (3), 461-482. Roman, P. (1988). Growth and transformation in workplace alcoholism programs. In M. Galanter (Ed.), Recent developments in alcoholism (pp. 131-158). New York: Plenum Press. Schuler, R.S. (1980). Definition and conceptualization of stress in organizations. Organizational Behavior and Human Performance, 25, 184-215. Spector, P.E. (1986). Perceived control by employees: A meta-analysis of studies concerning autonomy and participation at work. Human Relations, 39, 1005-1016. Zaltman, J., Duncan, R., and Holbeck. J. (1973). Innovations in organizations. New York: John Wiley & Sons.

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13 EAPs AND EARLY INTERVENTION: MAXIMIZING THE OPPORTUNITIES BRADLEY GOOGINS

INTRODUCTION The very concept of employee assistance programs (EAPs) is synonymous with early intervention and prevention. The conceptualization, rationale, and marketing of the EAP in its formative years evolved around its power in identifying, confronting, and intervening in the alcoholic employee's life before he or she hit bottom. Unlike the public inebriate, or the typical alcoholic seen in treatment at that time, the employee experiencing an alcoholic problem was usually surrounded by an intact family and work-based supports. More recently, P. Roman and T. Blum's (1988) core technology of EAPs describes the elements that appear to be primarily preventive in nature: identification of problems based on job performance, consultation and advice to supervisors and union stewards, and the strategy of constructive confrontation. All of these core elements underlie a critical dimension of the EAP—the ability to intervene at a significantly earlier stage than community or hospitalbased programs and thus heighten the chances of successful treatment. The use of job performance monitoring mechanisms such as performance appraisal instruments can help to surface the symptoms of alcohol abuse or alcoholism before more serious deterioration takes place and the employee slips further down the Jellinek curve. The presence of supervisors provides a built-in mechanism for implementing this strategy of early intervention. By serving as gatekeepers, supervisors are able to identify job performance problems such as absenteeism and tardiness which are often symptomatic of alcoholic behavior. In addition, they can begin to use this material to constructively confront the employee. By using the documented record of job impairment, through this jobfocused intervention strategy, it is possible to move the employee into treatment

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long before the problem would ordinarily surface and deteriorate into the more serious stages. Finally, the presence of a work environment usually presumes the presence of a home environment, both of which imply that the alcoholic in an EAP at work has sufficiently intact supportive environments. This, in turn, holds that treatment will be much more successful in an EAP environment than in those environments in which the handles to identify and confront persons such as the public inebriate do not exist. The reported rates of the treatment success of EAPs of from 60 to 70 percent, compared to the 30 percent success rates reported in community treatment, corroborate the reputed power of the EAP. Despite these highly touted advantages, a growing dissonance between the model and the practice of EAPs has begun to appear, particularly over the past several years. The numbers and percentages of supervisor referrals have typically declined significantly. Likewise, supervisor training, which prepared the supervisor to become an effective early intervention and prevention agent, has been either abandoned or minimized in many EAPs. A second measure of this dissonance is evidenced by the late stage at which many alcoholics arrive at the EAP. Although one would expect employees in the early stages of alcoholism to constitute the bulk of EAP caseloads, just the opposite appears to happen. One measure of this late-stage phenomenon is the frequent disintegration of the family prior to the identification of the problem at the EAP level. In a current National Institute on Alcohol Abuse and Alcoholism (NIAAA) supported research project, which examines the dynamics of alcoholism in families where both the husband and wife work, the original site, a well-established EAP, had to be dropped in favor of a hospital because so few EAP clients still had families who were functioning parts of their lives. (Ironically, the same situation existed in the hospital population indicating the predominance of late-stage alcoholics in the treatment system.) A second indicator of this phenomenon is the primary reliance on inpatient long-term treatment for EAP clients. In examining the range of treatment options, the option most frequently chosen is that of the long-term inpatient, which sets a model most suited for late-stage alcoholism (Schneider and Googins, 1988). Although the EAP is still able to deal with alcoholics who have not hit bottom by reason of their being employed, there is sufficient evidence to question the ability of the EAP to capitalize on the early intervention and prevention potential that has historically and conceptually underlain the very essence of the EAP. Alcohol education has been minimally present in most EAPs. The increasing reliance on self-referrals casts some doubts on the ability of the EAP to locate and bring into the EAP orbit those employees whose denial is such that some type of constructive confrontation will be necessary. It appears that the early intervention and prevention assumed to be so central to the EAP has, in fact, been more a figment of the EAP mystique than a reality. Because the population served is working and is thus visibly distinguishable from the public inebriate and the skid row alcoholic, who so captured the public perception of the alcoholic

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before the early 1970s, the prevention and early intervention may well be more relative than real. Nevertheless the potential for prevention remains high for EAPs. The remainder of this chapter focuses on two fundamental components of an early intervention program for EAPs. First is the recognition and incorporation of social supports into the ongoing operations of the EAP. Since any success in treatment outcome is highly correlated with the presence of positive social supports, it becomes critical that the EAP field become more aware of the nature and importance of social supports and the skill of incorporating this knowledge into EAP practice. Related to this broader concept is the more specific set of supports which are found in the home and family of the employee. Although the workplace has traditionally been seen as the point of early intervention, more recent evidence suggests that the family environment might actually play a more critical role in terms of early intervention, particularly when it is incorporated and tied to workplace interventions such as the EAP. The challenge for the EAP becomes how to incorporate social supports and family environments into the EAP. This attention to social supports and family environments comes along at an opportune time for EAPs. Over the past several years American corporations have been confronted with a new set of human resource issues related to families and dependent care. Reduced to its most basic dimensions, the issues center around the movement of women, and mothers in particular, into the work force, which is creating problems of child care, maternity leave, inflexible and outmoded benefits and policies, along with inadequate organizational structures to meet the needs of this new work force. As a result of the shifting work force demographics, many corporations, anticipating the projected labor shortage of the 1990s, are currently wrestling with child-care and dependent care issues as they increasingly impact the corporations' ability to attract and maintain a productive work force. It is suggested that this recent interest in dependent care signals a change in the very nature of the relationship between employer and employee, ending the dichotomy between work and family and incorporating the family into the work environment. It is this growing interdependence of work and family that constitutes a unique opportunity for EAPs to broaden their framework for conceptualizing their mission, and thus heighten the potential for early intervention and prevention. SOCIAL SUPPORTS The concept of social support has been defined in a number of ways in the research literature. Explaining one perspective, S. Cohen and S.L. Syme, for example, define social supports as "the resources provided by other persons" (1985,4). Two basic elements are associated with this definition: (1) as resources,

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social supports make accessible beneficial information, material items, behavior, or affective exchanges; and (2) these resources come directly from people, interpersonal relationships, or environmental systems (formal or informal) created by people. It is postulated that individuals benefit from the existence of social supports in many ways such as (1) reinforcing the person's well-being and sense of security (associated with the feelings of attachment to a social environment), (2) providing coping assistance, and (3) offering norms against which the individual can appraise both situations and appropriate responses (e.g., coping behaviors). Finally, J.S. House (1981) has outlined four dimensions of social support: (1) type of supportive acts (emotional, appraisal, informational, instrumental), (2) source (e.g., spouses, friends, relatives, supervisors, co-workers), (3) general versus problem-focused support, and (4) objective versus subjective assessment. Utilizing the multiple perspectives on social support, it is possible to conceptualize social support on a micro or macro level, ranging from the discrete act of providing social support to an individual seeking assistance for a substance abuse problem on one hand, and complex and encompassing social environments on the macro level. An isolated social exchange (single interaction) can have a neutral, positive, or negative impact on a person's well-being, growth, behavior, or coping abilities. For the purposes of clarity, a social exchange that has a positive impact can be seen as an "act of support." At the next level are "social networks" or "social relationships" that contain numerous social exchanges. Those relationships that become resources are part of an individual's "social support system." Within the social support system, some relationships are supportive (generally having a positive effect on the individual's well-being), while others are not. Thus an employee with an alcohol problem may be surrounded by a support network of fellow alcoholics, codependents, or those providing erroneous counseling. An individual's support system can include relationships with family members and relatives, friends, work associates, affiliates in groups, and professionals (e.g., therapists, counselors, clergy members). The mere existence of a social support system does not necessarily mean that an individual will recognize the availability of the resources connected with the support, seek out those resources, or accept the resources offered by support system members. M.B. Tucker (1982) discussed this issue in an analysis of women with substance-abuse problems, primarily heroin addiction. In order for an individual's support system to be activated, the person must perceive the existence of the support system resources and utilize them. There has been some limited investigation of the social support systems that exist at work. S.V. Kasl and J.A. Wells (1985) noted that the vast majority of social support studies examining the work setting are embedded in the stress-atwork perspective. This viewpoint assumes that work is a stressor rather than a support. The relationships across the settings of work and family are typically seen as strained (Googins and Burden, 1987). This work-family role strain is

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most evident when work is primarily operationalized as a stressor that can contribute to personal or family distress. Some earlier research has indicated that a positive relationship between health and well-being and job satisfaction can exist. A.H. Brayfield, R.V. Wells, and M.W. Strate (1957) and P.C. Smith, L.M. Kendall, and C.L. Hulin, (1969), among others, have examined job satisfaction and its relationships to the work itself, supervision, co-workers, promotional opportunities, and wages. Many of these factors are related to the constructs of the work environment and the existence of social support systems at work. More recent researchers have begun to explore the complexities of understanding how social supports vary by conditions, types of contacts, and the subjective expectations of the respondent (e.g., LaRocca and Jones, 1978; Winnburst, Marcellissen, and Kleber, 1982). A more complicated picture of social environments and supports in the family and the worksite emerges when these issues are examined along with stressful life events and some type of psychopathology (Monroe et al., 1986) or addictions (Mermelstein et al., 1986). In these and related studies, variables that measure support availability and its specific function in either promoting or impeding behavior change are examined. In the alcoholism literature, the availability of social environments and supports is often suggested to be related to treatment outcome (Cronkite and Moos, 1980; Finney, Moos, and Mewborn, 1980; Bromet and Moos, 1977). The literature also has identified a number of supports that act as social influences that affect behaviors. R. Jessor, M. Collins, and S.L. Jessor (1972), for example, identified peer pressure as an influence that often leads to the development of drinking in adolescence. Observational studies of barroom drinking have examined the influence of drinking groups in determining alcohol consumption (Sommer, 1965). Even D. Cahalan, I. Cisin, and H. Crossley's (1969) national survey of adult drinking practices identified the influence of social supports. Heavy drinkers with favorable attitudes toward drinking who live in environments permissive of heavy drinking will eventually become problem drinkers (Cahalan et al., 1969). W. Sonnenstuhl (1986) has been one of the few researchers who has examined similar phenomena within the workplace. His research has focused on the processes of informal networks in the absorption of deviant behavior into routinized social interaction on the actual resolution of alcohol or drug abuse without any formal system intervention. However, a careful mapping out and examination of the type, availability and functions of social environments and supports in both family and worksites remains to be identified. The evidence of the influence and impact of social supports is becoming well documented in a range of fields from gerontology to mental health. Although R. Moos (Cronkite and Moos, 1980; Finney, Moos, and Mewborn, 1980) has conceptualized work and family environments within the alcoholism literature, the nature and concept of social supports have had minimal discussion within the EAP literature. This is particularly interesting since the EAP was conceived

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within the systems context of work organizations. However, rather than lamenting what has not occurred, it might be more productive to focus on the potential of social supports for the EAP field. Utilizing a social support framework within the EAP reorganizes some of the basic EAP functions. From the viewpoint of early identification, the EAP can begin to determine the natural work groups which account for the normative standards that guide behaviors that occur. For example, in a large utility company, drinking norms evolve primarily out of work group norms rather than from some universal set of corporate standards or even a company-wide education campaign. In one sector, craftsmen drink their lunch at the local pub. In another sector, the marketing division has developed well-attended after-hours drinking clubs at the local cocktail lounge. Within any work organization, subgroups provide norms around drinking which contribute to both positive and negative drinking behavior. It is within these same work groups that social supports operate in the initiation and maintenance of alcoholism and drug abuse. Likewise these social supports can serve to assist alcoholic employees to achieve successful reintegration and rehabilitation following treatment. Yet today it is a rare EAP that operates to capitalize on the presence of these social supports. Prevention and education material and training are aimed primarily at the individual. Even supervisors, who constitute a separate and often discrete social network, are almost exclusively trained as individuals, and their natural networks are not even acknowledged, never mind put to work in addressing the company's alcohol and drug problem. The workplace offers unique and exciting territory within which the EAP is able to integrate its operations into already existing systems of support. However, the EAP has largely relied upon and borrowed from the medical and mental health models of operations. Thus they have centered primarily on intervention around the individual but usually to the detriment and neglect of the environment and the broader systems within the workplace. In relying on this more linear model, the EAP has missed the natural terrain of the workplace and the opportunity this brings with it for early identification, education, and prevention. EAP AND THE FAMILY Perhaps an even more neglected set of opportunities than the workplace setting has been the other leg of social supports—the family1 or the home environment. The evolution of employee assistance programs has taken place in large measure within the context of the individual employee and the work environment. The unique contribution of the EAP lies in its understanding of the work organization and its power to bring the existing structures and behaviors of the workplace to confront the employee's alcohol problem. Curiously, the other side of most employees' lives, their home and family environment, has been virtually ignored in this process. Although alcohol has been conceptualized as a family illness, the EAP, with its deep roots in alcoholism, assumed more of the culture

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of American workplaces in creating separate spheres of work and family. In doing so EAPs may have inadvertently overlooked a potential force in the development and maintenance of alcoholism and, at the same time, missed an opportunity to create an even more potent intervention drawing upon what Freud referred to as the two basic building blocks of all human behavior: work and love. By better understanding the role of families within the EAP, the power of the EAP is considerably enhanced in that it adds a dimension of social supports which parallels that of the work environment and recognizes the importance of home-based social supports in the prevention and treatment of substance abuse. THE WORLDS OF WORK AND FAMILY Just about the time EAPs were becoming a common feature within the workplace, corporations were also becoming more aware of the intrinsic relationship between employees and their households. The workplace had traditionally operated within narrow and parochial guidelines. The prevailing myth of separate worlds (Kanter 1977) has allowed work organizations to maintain firm boundaries which protect the primacy of productivity while denying the ownership or responsibility of individual and family problems. Nevertheless, the myth of separate worlds is now yielding to a more integrated state in which families and workplaces have become part and parcel of human existence. The dispelling of this myth has been brought about by a number of changing demographic realities. Consider for example: • Almost 60 percent of the mothers of children under age 18 were employed in the fourth quarter of 1985 (Bureau of Labor Statistics) • By 1995 more than 80 percent of women between the ages of 25 and 44 are expected to be working (U.S. Department of Labor) • Within the last decade, the labor force participation rate for married women with children under one year of age increased 70 percent (Bureau of Labor Statistics) • The divorce rate almost doubled between 1970 and 1980 (U.S. Census) • Ten percent of all children under the age of 18 live with only one parent—an increase of 53 percent since 1970 (U.S. Census) These are significant changes which have great impact on the workplace and on the culture and behaviors of work organizations. These changes are bringing with them a number of institutional changes that will redefine both the nature of work and the work environment. The motivation for change within corporations is not driven by a newly found value on individual and families or on an appreciation of workers' stress and struggle over balancing work and family roles and responsibilities. The changes in policy, programs, and behaviors which are taking place on multiple fronts are driven primarily by the necessity of adaptation. If corporations do not recognize and incorporate the new demograph-

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ics and values into their operations, they will suffer the same negative consequences brought on by failure to adopt new technologies. Since women, dualcareer families, and single parents will continue to be permanent fixtures within the workplace, corporate policy and practice will have to take into account their particular needs. To the extent that spillover of family and home into the workplace impacts productivity, corporations will have to become sufficiently motivated to become involved in finding and providing reasonable mechanisms or solutions. As the result of the rigid social and cultural changes delineated above, both workplaces and families are beginning to reexamine their roles and functions and their relationship to each other. This mutual reexamination starts however from a base of competing interests. Families, for example, have traditionally posed a threat to the workplace in breaking down the loyalty and commitment of its employees. To the degree that an employee is required or desires to expend time, energy, and affection outside the workplace, the likelihood is that there will be less time and attention on the productivity needs of the workplace. There is after all a finite pool of time and attention, and what one domain gains, the other often loses. Work likewise threatens the family by demanding increasing amounts of loyalty, by sometimes forcing separateness, and by often draining physical and emotional resources to the point that little is left for the family. These events, which continue to reshape the workplace radically, cannot and should not be lost in the design of EAP activities. At the very least it will require the EAP to recognize that it too is dealing with a changing workplace of people and values. Thus it will have to adapt its programs and strategies to serve better their needs and their households. It will also require a more integrated strategy with the human resource functions of the organization as employees and their families become more integral to the organization. But, more to the point of this chapter, the changes discussed above present EAPs with a unique opportunity to broaden their understanding of the alcoholic employee to incorporate the very interrelationships between work and family. While the corporation struggles with the debunking of the myth of separate worlds, the EAP can incorporate a more realistic and expanded system for dealing with alcoholic employees: the two worlds of work and family. This very system, which threatens the exclusive loyalty of the employee to the corporation, introduces to the EAP a unique opportunity to bring a more holistic and systemic approach for identifying, confronting, and treating the alcoholic employee. Bringing the family and home life into the EAP considerably enhances the potential for prevention, education, intervention, and treatment. This would suggest that, at the very least, the new opportunities to incorporate an employee's external environment (home and family) heightens the potential for early intervention and greatly increases the resources for assisting alcoholic employees. There are numerous opportunities for the EAP to incorporate the family into its practice and thus increase its ability to respond to the needs of its client

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system in the workplace. The first relates to the need to understand better the working functions of families and incorporate better these data into both the psychosocial assessment of families and the treatment of the wide range of problems that affect families. Most employee assistance practitioners have little awareness of family functioning outside their own experience. However, family dynamics constitute a field of practice which would be of great assistance to EAPs as they attempt to understand the social systems and supports that surround the individual employee sitting before them. This is particularly true in the case of the alcoholic. Alcoholism has long been conceived and presented as a family issue whose development usually takes place within family structures. The family support system constitutes a parallel system to the work system in shaping, promoting, discouraging, and facilitating the employee's alcoholism. Alcoholism develops within the family just as it does within the work environment, and any attempt to prevent or treat the alcoholic should incorporate this reality into its planning. Just as families are an essential context for the development of the problem, they also represent an essential component of intervening in the development of the problem and of rehabilitating the alcoholic to a functioning life without the drug. The treatment of alcoholism is augmented as much by the presence and support of the home environment as it is by the work environment. For alcoholics, the family often forms the source for continuous support along with their self-help network. Rarely, however, have the spouses or significant other household members been involved by EAPs in the initial phases of identification and assessment or in the ongoing treatment phases, with the noticeable exception of a few family-oriented treatment centers. In a typical EAP some brief family information might be taken at intake, and on very rare occasions family members might be brought into the process. The same is usually true at the referral point. It is quite rare, however, to find treatment in which the family may be involved in more than a weekend at which brief educational activities are offered. The likelihood of family involvement at followup is even more remote. The absence of family involvement is partially explained by a set of complex variables such as insurance and reimbursement policies which do not recognize or compensate for family involvement, lack of fit with prevailing ideologies (Alcoholics Anonymous and self-help movements have not included the family to any great extent in their conceptualization), and staff who are not trained to deal with family dynamics. The current research being conducted by B. Googins on the dynamics of alcoholism in working families indicates that the many obstacles to family involvement are greatly appreciated by practitioners. Nevertheless, the compelling arguments relative to treatment success being tied to family involvement suggest that, if success rates are going to improve and employees are going to be identified at an earlier stage, the EAP field, along with the treatment community, will have to seek more earnestly those strategies that encourage substance abusers' families and households to become involved with the process. The treatment research

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literature suggests that early intervention increases the likelihood of positive outcomes for the alcoholic and thus by extension to the overall health and functioning of the person's support system. Delayed or late intervention and treatment not only jeopardize alcoholics, but also place their support systems (especially the family) at risk. Thus it appears that the involvement of the family will increase the likelihood of positive treatment outcomes and also will support the functioning of the family. A second and more complex issue for EAP involvement with families lies in the growing area of dependent care. Over the past several years one of the most pressing and immediate needs for families and corporations is the care of children, the disabled, and elderly parents. Since the responsibility for such care has rested primarily on the family, the movement of the traditional caretaker (the woman) into the workplace over the past decade has begun to impact the corporation as the stress of managing both work and home responsibility spills over into the workplace and impacts productivity. Although the impact on families is different from the impact on the corporation, it nevertheless represents at the least a shared concern. The family roles and responsibility for children, aging parents, and infirm or disabled family members are real and are tied to traditional social, cultural, and religious mandates. As adult family members spend significantly more time within the workplace, not only is there less time and more conflicts in dependent-care responsibility, but also an increased expectation that the employer will share the burden and responsibility. This is most manifest in the benefit arena, but it is increasingly finding its way into organizational policy, procedures, programs, and behaviors. This issue of appropriate roles for the EAP is far from clear. On the one hand, the EAP is confronted daily with the stress of families who are trying to balance and manage their work and home roles and responsibilities. Reports from most EAP data bases confirm this reality in that family issues constitute the highest percentage of total cases. Thus, like it or not, the EAP finds itself in the midst of this issue. However, EAPs are also caught in organizational role conflict. Although the issues of child care, parental leave, flextime, family benefits, and elder care are coming to the forefront of employees' lives and the corporate human resource agenda, they are not in the domain of the core technology of the EAP. Although no one expects the EAP to jump into the middle of these issues, it would be strategically unwise for it to absent itself on the grounds of EAP pureness and incompatibility with its mission. The issues of employees' balancing their work and home roles and responsibilities are creating stress on both the individual and organizational levels. EAP specialists should be aware of these stresses and tailor their programs to assist employees in reducing work/ home conflict. Even at the organizational level it is most appropriate for the EAP to work with the organization to understand better the extent and nature of these problems and to explore the range of strategies, policies, and programs that would help it to respond better to employee needs.

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CONCLUSIONS The concept of early intervention, which has so marked the reputation and perceived effectiveness for the employee assistance movement, has remained relatively unexamined beyond its most basic properties. Clearly, the signs of early intervention and prevention from some quarters seem less and less real within today's environment. Although EAPs have indeed carved out a population whose characteristics are sufficiently delineated from the public inebriate to justify the claim to early intervention, the relativity of the early characteristics of this intervention can be put to further scrutiny. The anecdotal evidence (in the absence of empirical findings) suggests that the alcoholic entering the EAP is indeed more late stage than early. With the possible decline of formal supervisor referrals, it could be argued that early intervention and prevention are even less likely over the next decade. The deliberate recognition and incorporation of social supports into the EAP serves to broaden the environments in which EAPs assess and intervene on individual and organizational levels. This chapter has argued for the EAP to undertake such a broadening process by drawing upon the natural social systems of work groups and by utilizing the family in parallel fashion. It is suggested that the failure to incorporate social supports in general and family systems in particular has denied potentially valuable prevention and early intervention arenas for EAPs. The more traditionally narrow focus on the individual employee with the problem ignores the context of work environments and households where the problems of alcoholism and drug addiction evolve and progress. By recognizing the possibility of involving families and other work-based social supports, the EAP has the potential for pushing back the identification process of early intervention and prevention. Bringing such a systems perspective to the EAP and involving families in the EAP process might well open up a truly early identification which would maximize the EAP's mission and potential. NOTES Support from Grant No. R01-AA-06094 from the National Institute on Alcohol Abuse and Alcoholism is gratefully acknowledged. 1. It is important to note that even the use of family within the context of today's work force has to be qualified by home environments. The typical family unit no longer consists of wife at home, 2.2 children, etc. Rather a multiplicity of household compositions exists within the workplace including nonmarrieds, gays, single parents, blended families, and so on. Thus, it is only for reader convenience that the generic term * 'family" is employed. REFERENCES Brayfield, A.H., Wells, R.V., and Strate, M.W. (1957). Interrelationships among measures of job satisfaction and general satisfaction. Journal of Applied Psychology, 41, 201-205.

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Bromet, E.T., and Moos, R. (1977). Environmental resources and the post treatment functioning of alcoholic patients. Journal of Health and Social Behavior, 18, 326-335. Cahalan, D., Cisin, I., and Crossley, H. (1969). American dri?iking practices. New Haven, CT: College and University Press. Cohen, S., and Syme, S.L. (Eds.). (1985). Social support and health. Orlando, FL: Academic Press. Cronkite, R . C , and Moos, R. (1980). Determinants of the post treatment functioning of alcoholic patients: A conceptual framework. Journal of Consulting and Clinical Psychology, 46, 305-316. Finney, J.W., and Moos, R.H. (1984). Environmental assessment and evaluation research: Examples from mental health and substance abuse programs. Evaluation and Program Planning, 7, 151 -167. Finney, J., Moos, R., and Mewborn, C.R. (1980). Post-treatment experiences and treatment outcome of alcoholic patients six months and two years after hospitalization. Journal of Consulting and Clinical Psychology, 48 (1), 17-29. Googins, B., and Burden, D. (1987, August). Vulnerability of working parents: Balancing work and home roles. Social Work, 295-308. House, J.S. (1981). Work, stress and social supports. Reading, MA: Addison-Wesley. Jessor, R., Collins, M., and Jessor, S.L.(1972). On becoming a drinker: Social psychological aspects of an adolescent transition. Annals of New York Academy of Sciences, 197, 199-213. Kanter, R.M. (1977). Work and family in the United States. New York: Russell Sage Foundation. Kasl, S.V., and Wells, J.A. (1985). Social support and health in the middle years: Work and family. In S. Cohen and S.L. Syme (Eds.), Social support and health (pp. 175-198). New York: Academic Press. LaRocca, J., and Jones, A. (1978). Co-worker and leader support as moderators of stressstrain relationships in work situations. Journal of Applied Psychology, 63, 629634. Mermelstein, R., Cohen, S., Lichtenstein, E., Baer, J.S., and Kamarck, T. (1986). Social support and smoking cessation and maintenance. Journal of Consulting and Clinical Psychology, 54, 447-453. Monroe, S.M., Connell, M.M., Bromet, E.J., and Steiner, S.C. (1986). Social support, life events, and depressive symptoms: A 1-year prospective study. Journal of Consulting and Clinical Psychology, 54, 424, 431. Roman, P.M., and Blum, T.C. (1988). The core technology of employee assistance programs: A reaffirmation. Almacan, 18, 17-21. Schneider, R., and Googins, B. (1989). Alcoholism day treatment: Rationale, research and resistance. Journal of Drug Issues, 19, 437-449. Smith, P.C., Kendall, L.M., and Hulin, C.L. (1969). The measurement of satisfaction in work and retirement. Chicago: Rand McNally. Sommer, R. (1965). The isolated drinker in the Edmonton beer parlor. Quarterly Journal of Studies on Alcohol, 26, 95-110. Sonnenstuhl, W. (1986). Inside an emotional health program: A field study of workplace assistance for troubled employees. Ithaca, NY: 1LR Press. Tucker, M.B. (1982). Social support and coping: Applications for the study of female drug abuse. Journal of Social Issues, 38, 117-137. Winnburst, S.A.M., Marcelissen, F.H.G., and Kleber, R.J. (1982). Effects of social support in the stressor-strain relationship. A Dutch sample. Social Science and Medicine, 16, 475-482.

14 THE BYSTANDER-EQUITY MODEL OF SUPERVISORY HELPING BEHAVIOR: PAST AND FUTURE RESEARCH ON THE PREVENTION OF EMPLOYEE PROBLEMS LAWRENCE H. GERSTEIN

Impaired job performance has been linked to a number of non-worksite difficulties including drug, alcohol, family, emotional, and financial problems (Myers, 1985; Prien et al., 1979; Trice and Beyer, 1984). Alcoholism, for instance, has been estimated to afflict between 5 and 10 percent of the work force; drug abuse affects from 3 to 7 percent of the working population (Quayle, 1985). The cost to industry of substance-abusing workers has been well documented (Halpern, 1972; Myers, 1985; Scanlon, 1986; Scher, 1973). These employees cost organizations billions of dollars each year (Scanlon, 1986) because, compared to nonaddicted workers, their absenteeism rates are two-and-one-half times higher, their consumption of medical benefits is three times greater, their compensation claims are five times more frequent, and their garnishments occur seven times as often (Wrich, 1986). In response to these costs, the American business community was introduced to occupational alcoholism programs (OAPs), which later evolved into employee assistance programs (EAPs). These programs were designed to provide a worksite setting where employee intervention (e.g., counseling) could take place. They were also constructed to deal with a variety of employee substance- and nonsubstance-abuse difficulties, particularly alcoholism (Jerrell and Rightmyer, 1985; Roman and Blum, 1985). Workers with these problems were expected to receive OAP/EAP services through self-referral, supervisor referral, secondary referral (by a co-worker, family, or friend), or disciplinary or grievance board referral (Gerstein and Bayer, 1988a; McClellan, 1982). While self- and supervisory referrals have contributed the bulk of troubled workers receiving EAP services, EAPs have focused their efforts on increasing the number of supervisory referrals (Bayer, 1987; Masi, 1984; Trice and Roman, 1978; Wrich, 1980). These programs have trained supervisors to identify im-

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paired workers through the tracking of attendance, productivity, and co-worker difficulties (Bayer and Gerstein, 1988a). Supervisors have learned that frequent absences, poor job performance, impaired interpersonal relations (Bayer and Gerstein, 1988a; Dunkin, 1981; Shain and Groeneveld, 1980), chronic alcoholism, drug abuse, anxiety, and depression (Dickman and Emener, 1982) are problems reflective of employees in distress. Supervisors have also learned how to confront employees with their observations and, if the ensuing discussion reveals that the problem is unconnected to the job, how to refer such persons to the EAP. This series of events is called 4 'constructive confrontation" (McClellan, 1982; Roman, 1980; Roman and Blum, 1985; Roman and Trice, 1968; Trice and Sonnenstuhl, 1985). Constructive confrontation has been described as: lt a series of confrontations, each giving the message a little stronger and leading eventually to disciplinary action and firing, if the employee does not take corrective action, but at each interaction indicating the availability of help for the problem and support within the organization if the employee seeks such help" (Foote and Erfurt, 1981, 219). Not surprisingly, EAPs have viewed this type of intervention as instrumental in the rehabilitation of problem workers (Wilcox, 1985). Some EAP investigators have even referred to this strategy as a form of secondary prevention, suggesting that the worksite is an excellent place to initiate the early identification and confrontation of troubled employees (Roman, 1981; Trice and Roman, 1972).

THE IMPAIRED EMPLOYEE HELPING PROCESS Critique of Theoretical Models Research on the supervisor-troubled worker identification, confrontation, and employee assistance or alcohol referral process has a fairly long tradition which dates back to the seminal studies conducted by H. Trice (1957, 1964) and M. Maxwell (1960) on job behaviors associated with alcohol usage. Over the years, various aspects of this process have been investigated including factors that inhibit supervisors' willingness to engage in referrals, characteristics of impaired workers, the effectiveness of EAPs, and features of organizations offering such programs. No doubt, these efforts have contributed to a better understanding of the impaired members of our work force and these workers' need to receive psychological or some other form (e.g., financial) of treatment. In turn, the information gathered as a result of these efforts has probably facilitated the earlier identification of troubled employees and the development of remedial and preventive programs to assist these persons. In fact, workers and employers have been shown to benefit from these programs financially (e.g., the workers retain gainful employment and the employers maintain rather than replace impaired workers) and psychologically (e.g., reduction in emotional distress for employees and work groups) (Asma, 1975; Asma et al., 1980; Chopra, Preston, and Gerson,

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1979; Scanlon, 1986; Shain, Suurvali, and Boutilier, 1986; Quayle, 1985; Trice and Beyer, 1984). Although a vast amount of research has focused on the effectiveness of EAPs, as well as factors related to workers' participation in such programs, surprisingly, much of this research has been a theoretical or void of any clearly articulated set of theoretical constructs. Some investigators (Beyer and Trice, 1984; Trice and Bayer, 1979, 1984) have implied that their research is theoretically based. But, even H. Trice and his associates have minimally described the basic tenets of their social control and comparison theory as it relates to EAP settings. Perhaps the most elaborate attempt to operationalize this theory has been offered by Trice, Roman, and others interested in one concept or procedure linked to this theory: the supervisor-employee constructive confrontation process (Beyer and Trice, 1978; Googins and Kurtz, 1981; Roman, 1982; Roman and Trice, 1968; Trice and Roman, 1971, 1972). These researchers have continued to describe the basic underlying structure of this process and have used this information to develop hypotheses for a variety of empirical studies. One exception to this paucity of theoretical research will be discussed later in this chapter. The results of some studies based on G. Bayer and L. Gerstein's (1988b) bystander-equity model of supervisory helping behavior are presented, together with an overview of their newly introduced theory. A framework for future research stemming from this model will be presented as well. In general, there are a number of reasons why EAP researchers have failed to develop or articulate theories to explain the supervisor-troubled employee helping process. First, historically, this process was based on a model that endorsed principles (Twelve Steps of Alcoholics Anonymous) introduced to offer assistance to alcohol abusers in the general population. As such, researchers may have relied too heavily on this model, ignoring the development of unique theories to describe the supervisor-alcohol abuser identification and helping process in the workplace. Next, with the rapid increase in alcohol abuse in the workplace during the last century and the apparent need to offer services to abusers, investigators may have been motivated to explore the pragmatics of treating these persons instead of designing theories to explain the helping process. Related to this, organizations offering EAPs probably saw that they had more to gain in having researchers implement and evaluate cost-effective programs to rehabilitate problem workers than in having these persons construct models to describe the fundamental dynamics of the helping process. Traditionally, since many EAP researchers have worked closely with industry, this explanation seems reasonable. Finally, this failure on the part of investigators to construct theories to explain the supervisor-troubled employee helping process may be a function of the stage of development of the EAP field. Given that this field is relatively young, it is possible that researchers decided to observe and collect data on various aspects of this process before developing theories to integrate different hypotheses and constructs. Regardless of the reason for why EAP research has not been firmly grounded

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in theory, it is imperative that this situation change. Theories are needed in order to integrate earlier findings and provide a unifying structure to evaluate more closely the supervisor-impaired employee helping process. Such theories ought to generate new, testable hypotheses that, hopefully, will result in more focused research. A framework for integrating new findings ought to result from such efforts as well. Additionally, the establishment of a firm theoretical foundation to explain the supervisor helping process should provide the framework for investigating how to reach all employees who need EAP services, not just those traditionally recognized and referred by supervisors. The construction of such theories should also contribute to the development and evaluation of highly specific supervisory training programs on the identification, confrontation, and EAP referral process. Similarly, it ought to improve the type and quality of preventive and remedial services offered to impaired workers. Finally, the accumulation of data to test and validate these theories should enhance the credibility of the research conducted by EAP investigators as viewed by organizational and vocational psychologists and applied social psychologists interested in constructs (e.g., career satisfaction, work adjustment, group dynamics) somewhat related to the supervisor-troubled employee helping process. Critique of Research Designs In addition to the lack of theories of workplace helping processes, it is not surprising that researchers interested in this topic have relied almost exclusively on the gathering of data through field designs that, in general, only lend themselves to correlational statistical procedures. For the most part, much of this research can be labeled as quasi-experimental, involving the use of passive observational methods to collect data (see Cook and Campbell, 1979). Such designs permitted EAP investigators to gather their data in an unobtrusive fashion in the naturally occurring work environment without manipulating any factors in this environment. In most instances, the integrity of the phenomenon being investigated was protected as a result of using these designs. These designs also enhanced the external validity or generalizability of the obtained results. Researchers interested in the effects of supervisory training on the troubled employee helping process also benefited from the use of these types of designs. In general, relying on quasi-experimental, randomized group designs (see Cook and Campbell, 1979), these persons evaluated the effectiveness of different kinds of training programs constructed to teach supervisors how to identify, confront, and refer problem workers (e.g., Belasco and Trice, 1969; Schramm, Mandell, and Archer, 1978). While the EAP field has advanced through the use of quasi-experimental designs, there is still a need to utilize other types of designs to enhance the internal validity of the results obtained thus far. In many instances, EAP investigators using quasi-experimental designs have not controlled intervening and

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confounding variables, leaving open the possibility of alternative explanations for the obtained results. K. Walker and M. Shain (1983) raised this very issue when they evaluated studies designed to investigate the effectiveness of EAPs for problem drinkers. These authors questioned whether researchers, when studying this topic, accounted for differences in (1) the procedures advocated by various EAPs, (2) the structure of the organizations offering EAPs, and (3) the characteristics of the workers receiving EAP services. They also raised some concerns about the ambiguity and type of job-related indices (only job behavior vs. drinking behavior, psychosocial adjustment, and job behavior) used in these studies to assess the effects of EAPs. Again, it is probably the case that EAP investigators avoided other types of designs used to enhance internal validity, particularly ones carried out in the laboratory, because of the constraints of the settings where the data were collected and because of the nature of the affiliations of the persons performing this task. Given the importance of internal validity when investigating any phenomenon, it is critical that EAP researchers begin to use more rigorous experimental designs which control for various intervening and confounding variables—a recommendation made by other EAP investigators (Googins and Kurtz, 1980; Kurtz, Googins, and Howard, 1984; Roman, 1980; Trice, 1980). Analog types of designs (see Berven, 1985; Heverly, Fitt, and Newman, 1984) used in laboratory and field settings with supervisors, employees, or EAP personnel would be helpful as would quasi-experimental, interrupted time-series designs (Cook and Campbell, 1979). Completely randomized factorial designs along with other types of true experimental designs would be helpful as well. By employing these designs, investigators could manipulate a variety of factors related to the supervisortroubled worker helping process. It would also be possible to examine this process over time (stability or reliability of obtained results) without the threat of any intervening factors that may operate in the work environment. Clearly, these designs provide the EAP field with an opportunity to investigate more closely the underlying structure related to supervisors' helping behaviors with impaired employees—a situation that should contribute to the field's theoretical advancement. These designs should make it easier to access data on supervisors' helping behaviors. They should also be less costly with respect to conducting EAP research and less vulnerable to the organizational constraints placed on the persons managing these projects. Use of these designs would fit more closely with the philosophic and methodological traditions of the psychology field as well and would increase the possibility of involving a larger number of psychologists in this area of research. THE BYSTANDER-EQUITY MODEL OF SUPERVISORY HELPING BEHAVIOR Thus far, various theoretical and methodological models found in the EAP literature have been critiqued. A need for more systematic theoretical EAP

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research has also been discussed, as well as a need for employing rigorous experimental designs when conducting such research. One model—known as the bystander-equity model of supervisory helping behavior (Bayer and Gerstein, 1988b)—might contribute to meeting these needs. The foundation for this model was established by integrating concepts from two extensively researched social psychological theories designed to explain prosocial behavior in the general population: the emergency intervention model (Piliavin et al., 1981) and the equity theory of interpersonal relationships (Walster [Hatfield], Walster, and Berscheid, 1978). Each of these models offers explanations for why potential helpers (bystanders) might behave altruistically with victims in different nonwork situations. The bystander model, for instance, focuses on various characteristics of the helper, victim, and situation as they affect the potential helper's level of arousal, the cognitions related to the costs of assisting, and the type of help offered. The equity model, in contrast, deals with the balance of rewards and costs inherent in helping relationships. As such, this model suggests that assistance occurs when potential helpers believe that the rewards outweigh the costs of offering help, or when these persons can maximize their gains in a relationship. When each of these models is adapted to the workplace, Bayer and Gerstein (1988b) suggest perceiving supervisors as potential helpers or bystanders and troubled employees as possible victims. The worksite was also viewed as the relevant situational environment where helping could occur. Given these assumptions, Bayer and Gerstein adapted concepts from each model to explain supervisors' willingness to help impaired employees. This adaptation also led to a variety of hypotheses about the supervisor-troubled worker identification, confrontation, and EAP referral process.

Situational or Worksite Characteristics The first set of hypotheses generated dealt with the characteristics of an employee's problem or work situation. Bayer and Gerstein (1988b) argued that supervisors would be more likely to identify a troubled worker if this person's problem were severe and easily recognizable. They suggested, for instance, that employees who abuse alcohol might be difficult to identify given their desire to mask their "mistakes, early departures, absenteeism, and physical symptoms with excuses designed to convey impressions of forgetfulness, family problems, or vague health concerns" (Bayer and Gerstein, 1988b, 28). Moreover, these persons might not be perceived as having severe problems, especially if their symptoms or excuses were viewed separately. Following from this, Bayer and Gerstein (1988b) hypothesized that supervisors would be more inclined to act prosocially with workers who displayed atypical or unpredictable behaviors.

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Employee and Supervisor Characteristics The next set of hypotheses focused on characteristics of the employee (victim) and the supervisor (helper). Similarities or differences between supervisors and employees in terms of sex, race, and common beliefs were expected to influence the supervisory helping process. In general, Bayer and Gerstein (1988b) predicted that supervisors would assist impaired workers who held similar beliefs and were of the same race. Additionally, male supervisors were expected to help female employees more often than male workers, whereas female supervisors were expected to assist subordinates of either sex less frequently than their male cohorts. Although not stated by Bayer and Gerstein (1988b), supervisors who were union members would also be more likely to help workers who were union members than those who were not. We-ness The third set of hypotheses (Bayer and Gerstein, 1988b) addressed a motivational state activated through a supervisor's identification with a troubled employee. This state, known as we-ness, was expected to be motivated by various inequities that could emerge within the supervisor-employee relationship. Given the natural bond between these persons, Bayer and Gerstein argued that supervisors would experience greater degrees of arousal once an inequity occurred in their relationships with subordinates. Such a situation could occur if workers failed to complete their job responsibilities or exhibited unpredictable behaviors. Simply put, Bayer and Gerstein hypothesized that greater degrees of inequity would result in higher levels of supervisory arousal, and would lead to prosocial behaviors. Personal and Organizational Costs Linked to Helping Bayer and Gerstein (1988b) also predicted that, as the supervisors' perceived costs of initiating a referral increased, their likelihood of enacting such a behavior decreased. For example, these theorists suggested that supervisory referrals would be viewed as costly if these persons experienced any obstacles when they tried to access their EAP (e.g., cumbersome procedures related to making referrals, restricted times to communicate with EAP staff, unfamiliarity with their EAP). Costly referrals, therefore, were "expected to be avoided by supervisors, whereas not so costly referrals (e.g., a simple phone call to a known counselor) [would be] carried out by supervisors" (Bayer and Gerstein, 1988b, 31). Supervisory Arousal and Potential Helping Responses The fifth set of predictions (Bayer and Gerstein, 1988b) was designed to explain the supervisory arousal process resulting from the interplay among the charac-

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teristics of the situation, the supervisors' identification (we-ness) with the troubled employee (victim), and the costs linked to helping. The supervisors' level of arousal was also thought to influence the type of helping response offered. Higher levels of arousal, occurring when the employee problem is recognizable and severe and we-ness exists, accompanied by low costs were expected to result in direct assistance by supervisors. For instance, if supervisors viewed an employee problem as serious, and if they experienced minimal costs related to making an EAP referral, Bayer and Gerstein (1988b) suggested that supervisors would initiate a referral. Conversely, they argued that if supervisors found it difficult to understand the worker's problem and if they felt that a referral would be personally costly, supervisors would avoid referring the employee. Finally, although not stated by Bayer and Gerstein (1988b), it follows that indirect types of supervisory assistance (e.g., advice, changes in job responsibilities) would occur under conditions of high cost and high arousal.

Equity and Supervisory Responses The last set of hypotheses (Bayer and Gerstein, 1988b) also dealt with the arousal process and the costs associated with helping. There are times when supervisors experience inequities in their relationships with their workers. Such inequities were thought to occur when employees did not fulfill their job responsibilities or when they failed to meet supervisory standards in terms of proper work attitude and commitment. Basically, these situations, according to Bayer and Gerstein (1988b), caused an imbalance or inequity in the ratio of costs to rewards inherent in the impaired employee's work group (e.g., supervisor-impaired employee transaction, troubled employee-peer interactions). More intense feelings of inequity on the part of supervisors, for instance, were expected to result from maintaining high-cost (to the work group and supervisor) problem employees. Bayer and Gerstein argued that these feelings of inequity would activate supervisors' arousal and concern about particular impaired employees and their work unit. They hypothesized that supervisors would use one of two strategies to restore equity: actual equity or psychological equity. Supervisors could, for example, take some action—performance conference, job termination or EAP referral—to modify an employee's poor job performance. This strategy attempts to restore actual equity in the work group and between supervisors and troubled individuals. Psychological equity, on the other hand, could be restored by supervisors' distorting an employee's past performance or contributions to the work unit. This strategy involves supervisors' changing their cognition about an impaired worker and the needs of the work group. Bayer and Gerstein (1988b) indicated that actual and psychological attempts to restore equity represent instrumental and subjective strategies used by supervisors to help problem employees.

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RESEARCH ON THE BYSTANDER-EQUITY MODEL OF SUPERVISORY HELPING BEHAVIOR Characteristics of the Situation and Helping Behavior Thus far, the results of a number of studies lend support to the various hypotheses just presented. As predicted, it was discovered that characteristics of the problem situation are related to the supervisor-troubled employee identification and arousal processes. When they used a 23-item instrument, known as the Behavioral Index of Troubled Employees (BITE), Bayer and Gerstein (1988a) found that supervisors recognize impaired workers by focusing on four distinct job behaviors. Results of a factor analytic study involving 237 industrial supervisors indicated that this group identifies impaired workers by noticing behaviors linked to resistance (R), acrimoniousness (A), industriousness (I), and disaffection (D). Behaviors on the R factor (six items) suggested that supervisors identify troubled employees by recognizing poor work attendance and conduct. This finding was consistent with earlier research that revealed that problem workers are tardy and absent more often (Schramm, Mandell, and Archer, 1978; Trice, 1957, 1964). Items on the A factor (four items), in contrast, indicated that employees who are irritable, angry, and contentious are labeled by supervisors as being troubled. Again, this result supported earlier research on characteristics of problem workers (Maxwell, 1960; Schramm, Mandell, and Archer, 1978; Trice, 1957). A similar label—troubled worker—is used by supervisors for employees who display poor productivity and impaired job performance; these behaviors, which are linked to the I factor (nine items), have also been discovered by other observers (Dunkin, 1982; Maxwell, 1960; Schramm, Mandell, and Archer, 1978; Trice, 1957). Finally, supervisors consider workers who are apathetic, alienated, and discontent to be troubled; these behaviors were connected to the D factor (four items). It is important to note that Bayer and Gerstein's (1988a) results obtained by using factor analytic and reliability procedures indicated that all of these factors were internally consistent and distinct. Thus, each BITE factor appeared to be reliable and adequate in terms of construct validity. More important, as expected, each factor seemed to represent supervisors' beliefs about the characteristics of situations or problems suggestive of impaired workers. Supervisors' beliefs about these situations were examined in another study conducted by Bayer and Gerstein (1989). In this project, the investigators explored how the severity of an employee's problem affected the supervisory helping process. Using an analog procedure, Bayer and Gerstein explored supervisors' helping behavior with 16 hypothetical workers. By manipulating the presence or absence of behaviors linked to each BITE construct, these researchers were able to vary the severity of a particular employee's difficulties and, presumably, the supervisors' level of arousal.

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As predicted, results suggested that supervisory EAP referral rates were significantly higher for workers who displayed severe problems compared to employees who exhibited minor difficulties. Additionally, it was discovered that the supervisors' decision to refer troubled persons for EAP services "were not just calibrated responses to the additive effect of increasing impairment, but were contingent responses to unique and dynamic combinations of information (e.g., job performance, work attitude, and dependability) about each hypothetical employee" (Bayer and Gerstein, 1989, 13). Thus, as hypothesized, findings from this study indicated that the severity of an employee's problem was linked to the supervisor's willingness to offer assistance and the supervisor's decisionmaking process.

Characteristics of Supervisors and Helping Behavior In another study, the supervisors' ability to identify behaviors suggestive of troubled workers was shown to be connected to job-related characteristics of this managerial group (Gerstein et al., 1989). Contrary to expectations, supervisors managing staffs of 17 or more subordinates, and with five years or more of experience in their current jobs, noticed more behaviors linked to the BITE resistance factor compared to persons supervising 16 or fewer workers. Gerstein et al. (1989) interpreted this finding by arguing that the former group of supervisors, by virtue of their limited contact with their employees, must learn to rely on concrete behaviors (e.g., unexcused absences, late arrivals) to recognize troubled workers. In yet another study designed to investigate supervisory characteristics and the identification of impaired employees, Gerstein et al. (in press) found that the supervisors who completed constructive confrontation training, compared to supervisors who had not participated in this activity, held more well-developed beliefs about two BITE factors or behaviors indicative of troubled workers: acrimoniousness and disaffection. This was not surprising, since training was expected to teach supervisors about the less obvious signs of impairment (e.g., being critical of others, complaining about illness). Training was also expected to help supervisors accept that it is permissible to refer workers who exhibit behaviors tied to acrimoniousness and disaffection. Somewhat different results were obtained by Gerstein et al. (in press) when they investigated the effects of supervisory training on beliefs about the two remaining BITE factors, industriousness and resistance. As anticipated, in the case of industriousness, supervisors who completed training and reported positive attitudes toward their EAP, in contrast to managers who reported positive and negative feelings about their EAP and did not attend training, were more inclined to consider behaviors linked to this factor as suggestive of impaired employees.

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The latter group may have believed that it was "their responsibility to help staff who displayed Industriousness problems" (Gerstein et al., in press) and not the responsibility of their EAP. Surprisingly, the supervisors' attitudes toward their EAP and their participation in training had no effect on this group's beliefs about the BITE resistance factor. When explaining this result, Gerstein et. al. (in press) suggested that it might be unnecessary for supervisors to participate in training to recognize that troubled workers display behavior linked to this factor (e.g., avoiding jobs, arriving late). Additionally, these researchers intimated that supervisors might be knowledgeable about behavior related to resistance regardless of their attitudes toward their EAP. A similar interpretation was offered by Gerstein et al. (in press) when explaining the fact that the supervisors' overall attitudes (positive or negative) toward their EAP had no effect on their beliefs about the BITE and acrimoniousness and disaffection factors. A few other studies lend support to hypotheses based on Bayer and Gerstein's (1988b) model. In one study, it was discovered that blue- and white-collar managers and employees differed in their beliefs about behaviors indicative of problem workers (Jankowski, Gerstein, and Valutis, 1989). Results of another study also suggested, as expected, that black and Caucasian supervisors and employers varied in their beliefs about these behaviors as well (Gerstein et al., 1989). Summary The results of the studies just presented provide general support for a number of hypotheses outlined in the bystander-equity model of supervisory helping behavior (Bayer and Gerstein, 1988b). As predicted, various supervisor characteristics and features of the situation or employee problem were linked to supervisory beliefs about and, to some extent, behaviors with troubled workers. Results from each study suggested that these characteristics differentially affect the supervisor-impaired employee identification and EAP referral process. Additional studies are still needed, however, to examine systematically how other variables mentioned by Bayer and Gerstein (1988b) influence this process. Some examples of such studies are discussed below. FUTURE RESEARCH ON THE BYSTANDER-EQUITY MODEL Substance-Abusing Employees Thus far, the research conducted by the bystander-equity model of supervisory helping behavior has focused on variables linked to the identification and referral of nonsubstance-abusing employees. As stated earlier, given the high incidence

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of alcohol and drug abuse among persons in our workplace (Quayle, 1985), it is rather important that future studies involving Bayer and Gerstein's (1988b) model investigate supervisors' beliefs about, and behavior with, substance-abusing subordinates. Results obtained from such research would not only contribute to our understanding of the supervisor-troubled employee helping process, but would also provide a more rigorous test of the bystander-equity model. Supervisory and Worksite Characteristics Keeping in mind the need to conduct more rigorous experimental research, the first study to be recommended would use valid and reliable psychometric instruments developed especially for this project. These devices would be used to gather data on the relationship between the identification of substance-abusing (e.g., alcohol, cocaine, Valium) employees and various characteristics of supervisors and their organizational settings. In particular, this study would investigate what influence the supervisors' positions in their organizational hierarchy (lower, middle, and upper management) have on their beliefs about behaviors indicative of substance- and nonsubstance-abusing workers. It would also examine the relationship between length of time in current supervisory position and these beliefs. Additionally, the association between the number of employees supervisors manage (span of control) and their beliefs would be explored. Finally, this study would determine whether supervisors from various organizational settings (social service, educational, industrial, and technical) differ in their beliefs about behaviors suggestive of substance- and nonsubstanceabusing workers. The next study to be recommended is also designed to investigate the relationship between the characteristics of supervisors (e.g., span of control, length of time in current job) and their organizational settings (e.g., social service, industrial) and this group's beliefs about substance-abusing employees. In this project, however, the supervisors' beliefs about how they might act with such workers would be explored. Using an analog methodology to simulate a variety of substance- and nonsubstance-abusing employees, the supervisors' expectations about referring these persons to their EAP would be examined. This methodology would be used to construct standardized scenarios that depict a variety of alcoholand drug-abusing (e.g., cocaine, marijuana) workers and other persons who display nonsubstance-abusing difficulties (e.g., resistance and acrimoniousness problems). It should be mentioned that these scenarios have been developed and used in two different projects that are currently being completed (Besenhofer and Gerstein, 1989; Gerstein and Lynn, 1989). Although this study could be criticized in terms of its external validity, it does provide an excellent alternative to investigating supervisors' actions with their employees at the worksite. Furthermore, it offers a technology that controls for various confounding and mediating variables and, as such, a protection for the internal validity of the constructs being studied (see Heverly, Fitt, and Newman, 1984; Kazdin, 1980). This technology also permits the manipulation of many variables, making it possible to draw conclusions about causation. In addition,

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it allows supervisors to respond to situations that probably could not be isolated in a naturalistic design, particularly when the temporal constraints of collecting data are considered. Finally, error variance can be reduced by using an analog design. Although many benefits are associated with analog research, relying on this methodology alone does not assure an adequate study: "a major challenge of analogue research is to construct stimuli that maintain a balance between experimental rigor and clinical reality" (Heverly, Fitt, and Newman, 1984, 45). In general, to meet this challenge, it is necessary to employ large numbers of "real" supervisors who are asked to respond to highly relevant employee problems. It is also important that the validity and reliability for each analogue be established. As stated earlier, results from each of the studies discussed thus far would further our understanding of the bystander-equity model of supervisory helping behavior. Additionally, these studies would fill a recognized gap in EAP research. Although many writers have addressed the importance of supervisors in the identification and referral of alcohol-abusing employees (Beyer and Trice, 1978; Chopra, Preston, and Gerson, 1979; Foote and Erfurt, 1981; Googins and Kurtz, 1980; Kurtz and Googins, 1979; Roman, 1982; Smart, 1974; Trice and Beyer, 1984; Wilcox, 1985), few empirical studies (Googins and Kurtz, 1981; Young, Reichman, and Levy, 1987) have systematically investigated the relationship between a variety of supervisory characteristics and the help offered to such workers (Hoffman and Roman, 1984). For instance, although research has been conducted to determined why professionals do not actively participate in EAPs either as referral agents or as clients (Jerrell and Rightmyer, 1985; Lee and Rosen, 1984; McClellan, 1982; Roman, 1980; Trice and Beyer, 1977), there is no data on this group's ability to identify and refer substance- and nonsubstance-abusing employees compared to persons of lower rank in an organization's hierarchy. There is also no data on how this ability might vary across job settings. In other words, it is not known whether mid-management and upper executive supervisors in social service facilities, for example, would behave more altruistically than their cohorts in industrial settings. Finally, it is not clear whether supervisors who are responsible for a small number of employees (e.g., 10 or less), as compared to a larger number (e.g., 11 or more), are more or less likely to notice substance- versus nonsubstanceabusing workers and to refer these persons for assistance.

Troubled Women and the Workplace A third recommended study would address an even more critical shortcoming in the EAP literature. Historically, much of the research on the supervisortroubled employee helping process has been conducted with male supervisors and male workers (Young, Reichman, and Levy, 1987). Consequently, there is a dearth of data on various aspects of female supervisors' helping behavior with

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subordinates of both genders (Gerstein and Bayer, 1989). Some researchers have investigated this topic by focusing on female supervisors' EAP referral behaviors with alcohol-abusing workers (Beyer and Trice, 1981; Young, Reichman, and Levy, 1987); others have simply discussed the implications of teaching women strategies to identify, confront, and refer these persons (Cahill, Volicer, and Neuberger, 1982; Trice and Beyer, 1979). As yet, no comprehensive study has been made to explore the differences between male and female supervisors in the identification, confrontation, and referral of male and female substance- and nonsubstance-abusing employees. No study that examines female supervisors' beliefs about troubled workers regardless of substance usage has been conducted either. As a step in this direction, the following study deals with potential differences between the sexes in terms of the problem employee identification process. As part of this project, a large number of female supervisors from various organizational settings would complete the BITE (Bayer and Gerstein, 1988a) and a biographical instrument constructed to gather data on the respondents' job responsibilities and job histories. Patterns in the participants' responses to the BITE would be examined and compared to the structure obtained in Bayer and Gerstein's original factor analytic study. Based on the bystander-equity model and the research conducted on helping behavior in the general population, females would be expected to be more attuned to behaviors loading on the disaffection (e.g., apathy) and acrimoniousness (e.g., anger) factors; males should be more aware of behaviors linked to the industriousness (e.g., meeting deadlines) and resistance (e.g., arriving late) factors. Assuming that male and female supervisors do vary in their recognition of behaviors indicative of impaired workers, it would become important to construct EAP training programs to address these differences. Women, for instance, might profit from programs that teach them more about productivity indices related to employee impairment. Men, on the other hand, might benefit from increasing the skills associated with the identification of a worker's interpersonal and intrapersonal difficulties. It is also conceivable that members of both sexes could learn from programs that teach them how to recognize subtle differences in work behaviors displayed by male and female subordinates.

A Systemic Perspective on Helping and the Family Up until now, the proposed studies have focused on supervisors and their troubled employees. Given the increasing importance of the connection between work and family systems (Ford and Ford, 1986; Friedman, 1986; Jankowski, Holtgraves, and Gerstein, 1988; Stackel, 1987) and the potential for these systems to be in conflict (Blood and Wolfe, 1960; Cooke and Rousseau, 1984; Greenhaus and Beutell, 1985; Jones and Butler, 1980), it is critical that future research examine the transactions beyond supervisors and their subordinates. In other

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words, research is needed to explore the interaction between families and work units, especially as this interaction affects the identified troubled employee. Again, Bayer and Gerstein's (1988b) bystander-equity model of supervisory helping behavior might be useful in conducting this research. Since family members, supervisors, and fellow workers can initiate an EAP referral, it may be interesting to examine how the interactions among these persons influence the potential helpers' level of arousal, the attributions linked to this arousal, and the costs associated with offering assistance (e.g., EAP referral). Such a study could contribute to an understanding of the situations that motivate family members, supervisors, and co-workers to be altruistic with impaired employees. In addition to investigating the connection between work and family systems, it also seems necessary that studies focus on the similarities between work and family units in terms of roles, power, boundaries, alignments, and structure (Jankowski, Holtgraves, and Gerstein, 1988). This is particularly important when the ways in which work groups might function when one or more members abuse alcohol are considered. It is conceivable that work units composed of such members operate as dysfunctional alcoholic family systems (Baum-Baicker, 1984; Jankowshi, Holtgraves, and Gerstein, 1988). If this is the case, it may not be effective to treat only the identified problem employee; the entire work group, including the supervisor, might profit from an EAP intervention. By pursuing a "work unit confrontation/intervention," it might be possible to avoid a vicious cycle, in which alcohol-abusing employees are returned to dysfunctional work systems that maintain and enable the abuse (Jankowski, Holtgraves, and Gerstein, 1988). Although the practice of treating the alcoholic work group in addition to the abusing employee is at odds with traditional EAP practices, it is consistent with the current emphasis in counseling to include the abuser's family in treatment (Royce, 1981). Obviously, research is needed to explore whether a work unit confrontation/intervention can effectively reduce the recurrence of alcohol difficulties and strengthen the performance and interpersonal relationships of employees affiliated with dysfunctional alcoholic work groups. If this strategy were found to be effective, the EAP field and business community could benefit from learning how to use this new, secondary prevention technique. It is likely, for instance, that by using this approach, each member of a work unit "would become educated sooner about the dynamics of their group and the potential employee problems that could emerge" (Jankowski, Holtgraves, and Gerstein, 1988, 109). This could facilitate communication between work units and EAPs and potentially reduce the number of employees needing EAP services. A Test of Various Supervisory Training Programs Throughout the history of the EAP movement, it has been important to train supervisors how to identify, confront, and refer troubled employees, particularly alcohol-abusing persons (Etchen and Roman, 1977; Foote and Erfurt, 1981;

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Googins, 1975; Sonnenstuhl and Trice, 1986). Although researchers have investigated the effect of training programs on supervisors' abilities to engage in such behaviors (Belasco and Trice, 1969; Googins and Kurtz, 1979; Trice and Belasco, 1968), there have been few studies (see Belasco and Trice, 1969) on supervisors' abilities to help impaired workers as a function of participation in different types of programs. The last study to be recommended here addresses this shortcoming. Supervisors affiliated with company-based or community-based EAPs would be recruited for this project. These persons would be randomly assigned to one of four training groups. The first group would teach supervisors to implement the more traditional work-related behavioral assessment model. These supervisors would learn to identify troubled employees by means of attendance records, absenteeism, strained interpersonal relations, substandard production, and safety transgressions. The second group, in contrast, would educate supervisors on how to use the constructive confrontation approach to facilitating employee intervention and referral (Delaney, 1984; Trice and Sonnenstuhl, 1985). The third group would teach the bystander-equity model of helping behavior and show supervisors how to use the concepts from this model to evaluate the dynamic interactions that occur among themselves, their staff, the work environment, and their employees' problems. This group would also help supervisors to learn about the personal and organizational costs and constraints of helping. The fourth and final group would operate as a control group; it would receive no training. Participants in each of the three experimental groups would receive about ten hours of highly specialized training. Didactic and role-playing strategies would be the primary learning methods used in each of these groups. Persons leading the groups would receive standardized instructions on how to implement their training program. To compare the effectiveness of these training programs, it would be necessary to collect information on characteristics of the supervisors (e.g., span of control, position in the organizational hierarchy) and to determine the supervisors' EAP referral rates, types of referrals, reasons for making referrals, and costs associated with this activity. These data would be gathered 3,6, and 12 months after the supervisors have completed their training, making it possible to assess the longterm effects of participating in different kinds of supervisory training. Results of this study should also make it possible to evaluate systematically the importance of designing training programs geared to characteristics of supervisors and the employees they manage (Trice and Belasco, 1968; Trice and Beyer, 1977). FUTURE DIRECTIONS FOR WORKSITE RESEARCH: A COMMENT Most of the ideas and recommendations offered in this chapter can be traced to a philosophical orientation endorsed by the field of psychology. As stated earlier, much of the research that has been conducted on the supervisor-troubled

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employee helping process has not been experimental nor driven by clearly defined theoretical constructs. This research has, however, made a substantial contribution to understanding how supervisors identify, confront, and refer impaired workers to EAPs. Through the use of a variety of observational research methods designed to ensure the external validity of the obtained results, previous investigators were able to uncover some general dynamics related to supervisors' action with troubled employees. At this time, an integration of observational and experimental approaches to collecting data at the worksite would increase the possibility of conducting research that is internally and externally valid. Furthermore, such an integration could result in the development of a number of theoretical models designed to explain the supervisor-impaired worker helping process, especially the process that involves alcohol-abusing employees. Since sociologists have been responsible for conducting most of the research in the EAP field, this group has the expertise in using observational techniques to gather data at the worksite. In addition, this group seems to have generated many potential hypotheses that could be woven into a tightly constructed theory to describe the supervisory helping process. Psychologists, on the other hand, can contribute to an understanding of this process by sharing their expertise in experimental design and procedures used to conduct rigorous, theory-driven research. This collaborative research model provides a structure that meets a need identified in the EAP literature (Gerstein and Bayer, 1989; Gerstein and Bayer, 1988b; Sonnenstuhl and Trice, 1986). That is, this model suggests a way for psychologists and sociologists to incorporate insights from each other's disciplines into their own work (Sonnenstuhl and Trice, 1986). Given the urgent need for additional EAP researchers (Kurtz, Googins, and Howard, 1984; Trice, 1980) and the fact that few psychologists have responded to this need, it becomes even more important that sociologists and psychologists currently pursuing EAP research learn to cooperate and collaborate on various projects in the workplace. This also means that both groups must develop an appreciation for mentoring the talents and expertise of psychologists and sociologists interested in the EAP field. CONCLUSIONS Throughout this chapter, I have argued for the development and elaboration of theoretical models to explain clearly the helping process involving supervisors and their subordinates. In addition, I have pointed out the need to conduct true experimental research on this process—research that protects both the external and internal validity of the obtained results. One theoretical model, the bystanderequity theory of supervisory helping behavior, has the potential to serve as a framework when pursuing such research. This model offers investigators a number of explicit, testable hypotheses that can be explored at the worksite and in

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the laboratory. Moreover, it provides a structure that may be used to integrate previous findings, so that EAP researchers and practitioners can understand more completely the dynamic nature of the supervisory helping process. This chapter has summarized the results of some studies designed to test hypotheses derived from the bystander-equity model. Recommendations for pursuing additional studies based on this model were presented as well. Suggestions were made for at least five different projects: substance-abusing workers, women, families of troubled employees, work units, and the training of supervisors to identify, confront, and refer subordinates who display job-related difficulties. A new and valuable technology for conducting cost-efficient, experimental EAP research was also introduced. Investigators were encouraged to use analog designs, so that they could manipulate various factors associated with supervisors' willingness to help impaired workers. Finally, I made a case for closer collaboration and cooperation between sociologists and psychologists as they continue to investigate transactions involving supervisors, workers, family members, and EAP personnel. As a step in this direction, I briefly outlined how each discipline's unique philosophy and research technology can contribute to a further understanding of such transactions. Ultimately, this understanding should lead to the strengthening of the secondary prevention strategies used to identify, confront, and help troubled members of the American work force. Presumably, the more effective these strategies are, the earlier employees would receive assistance and avoid the discomforts and costs of being impaired. Organizations would benefit from more effective secondary prevention strategies as well.

NOTE I want to thank members of my EAP research team (Lisa Baumgartner, Michael T. Brown, Joan Pfaller, Marnell Holtgraves, Jon Jankowski, Jill Losey, David Lynn, Daniel Tess, William Valutis, and Ron Wilcoxson) for sharing many ideas that helped shape this chapter. I am also appreciative of Karen Novak's editorial assistance and her constant support during the writing of this project.

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Troubled Employees (BITE). Unpublished doctoral dissertation, Ball State University. Muncie, IN. Bayer, G., and Gerstein, L. (1988a). Supervisory attitudes toward impaired workers: A factor analytic study of the Behavioral Index of Troubled Employees (BITE). Journal of Applied Behavioral Science, 24, 413-422. Bayer, G., and Gerstein, L. (1988b). An adaptation of models of prosocial behavior to supervisor interventions with troubled employees. Journal of Applied Social Psychology, 18, 23-37. Bayer, G., and Gerstein, L. (1989). Helping troubled employees: Supervisors' decisionmaking behavior. Unpublished manuscript, Ball State University, Muncie, IN. Belasco, J., and Trice, H. (1969). The assessment of change in training and therapy. New York: McGraw-Hill. Berven, N. (1985). Reliability and validity of standardized case management simulations. Journal of Counseling Psychology, 32, 397-409. Besenhofer, R., and Gerstein, L. (1989). The supervisor referral process: Characteristics of supervisors, workers, and employee assistance programs. Unpublished manuscript. Ball State University, Muncie, IN. Beyer, J., and Trice, H. (1978). Implementing change. New York: The Free Press. Beyer, J., and Trice, H. (1981). A retrospective study of similarities and differences between men and women employees in a job-based alcoholism program from 1965-1977. Journal of Drug Issues, II, 233-262. Beyer, J.M., and Trice, H.M. (1984). The best-worst technique for measuring work performance in organizational research. Journal of Organizational Behavior and Statistics /, 95-115. Blood, R., and Wolfe, D. (1960). Husbands and wives. New York: Macmillan. Cahill, M., Volicer, B., and Neuberger, E. (1982). Female referral to employee assistance programs: The impact of specialized intervention. Drug & Alcohol Dependence, 10, 223-233. Chopra, K., Preston, D., and Gerson, L. (1979). The effects of constructive coercion on the rehabilitation process. Journal of Occupational Medicine, 21, 749-752. Cook, T., and Campbell, D. (1979). Quasi-experimentation: Design & analysis issues for field settings. Chicago IL: Rand McNally Publishing Company. Cooke, R., and Rousseau, D. (1984). Stress and strain from family roles and work-role expectations. Journal of Applied Psychology, 69, 252-260. Delaney, T. (1984). EAP challenge to the alcoholism held. Digest of Alcoholism Theory & Application, 3, 46-50. Dickman, F., and Emener, W.G. (1982). Employee assistance programs: Basic concepts, attributes and an evaluation. Personnel Administrator, 27, 55-62. Dunkin, W. (1981, March). The EAP movement past and present. Alcoholism, 27-28. Dunkin, W. (1982). A brief history of employee alcoholism/assistance programs. LaborManagement Alcoholism Journal, 11, 165-168. Etchen, L., and Roman, P. (1977). Model of supervisory training for the implementation of employee alcoholism programs: Derivation through the Delphi technique. Working paper. New Orleans: Tulane Center for Monitoring Occupational Programs. Foote, A., and Erfurt, J. (1981). Effectiveness of comprehensive employee assistance at reaching alcoholics. Journal of Drug Issues, 11, 217-232.

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Ford, J.D., and Ford, J.G. (1986). A systems theory analysis of employee assistance programs. Employee Assistance Quarterly, 2, 37-48. Friedman, E. (1986). Emotional process in the marketplace: The family therapist as consultant with work systems. In L. Wynne, S. McDaniel, and T. Weber (Eds.), Systems consultant: A new perspective for family therapy (pp. 398-422). New York: Guilford Press. Gerstein, L., and Bayer, G. (1988a). Employee assistance programs: A systemic investigation of their use. Journal of Counseling and Development, 66, 294-297. Gerstein, L., and Bayer, G. (1988b). The future of employee assistance programs: An interdisciplinary perspective. Symposium presented at the annual meeting of the American Psychological Association, Atlanta, GA. Gerstein, L., and Bayer, G. (1989). Counseling psychology and the future of EAP research. Unpublished manuscript. Ball State University, Muncie, IN. Gerstein, L., Eichenhofer, D., Bayer, G., Valutis, W., and Jankowski, J. (in press). EAP referral training and supervisors' beliefs about troubled workers. Employee Assistance Quarterly. Gerstein, L., Jankowski, J., Bayer, G., Eichenhofer, D., and Valutis, W. (1989). Supervisory characteristics and beliefs about troubled employees. Unpublished manuscript. Ball State University, Muncie, IN. Gerstein, L., and Lynn, D. (1989). Supervisory referrals with substance abusing employees. Unpublished manuscript. Ball State University, Muncie, IN. Gerstein, L., Valutis, W., Brown, M., and Reese, L. (1989, August). Racial differences related to potential helpers' perceptions of impaired employees. Paper presented at the annual meeting of the American Psychological Association, New Orleans, LA. Googins, B. (1975, November). Employee assistance programs. Social Work, 464-468. Googins, B., and Kurtz, N. (1979, July-August). Supervisory networks: Toward an alternative training model. Labor Management Alcoholism Journal, 35-40. Googins, B, and Kurtz, N. (1980). Factors inhibiting supervisor referrals to occupational alcoholism intervention programs. Journal of Studies on Alcohol, 41, 1196-1208. Googins, B., and Kurtz, N. (1981). Discriminating participating and nonparticipating supervisors in occupational alcoholism programs. Journal of Drug Issues, 11, 199-216. Greenhaus, J., and Beutell, N., (1985). Sources of conflict between work and family roles. Academy of Management Review, 10, 76-88. Halpern, S. (1972). Drug abuse and your company. New York: American Management Association, Inc. Heverly, M., Fitt, D., and Newman, F. (1984). Constructing case vignettes for evaluating clinical judgement: An empirical model. Evaluation & Program Planning, 7, 4 5 55. Hoffman, E., and Roman, P.M. (1984). Effects of supervisory style and experientially based frames of reference on organizational alcoholism programs. Journal of Studies on Alcohol, 45, 260-267. Jankowski, J., Gerstein, L., and Valutis, W. (1989, August). The blues and whites: Staff members' impressions of troubled workers. Paper presented at the annual meeting of the American Psychological Association, New Orleans, LA. Jankowski, J., Holtgraves, M., and Gerstein, L. (1988). A systemic perspective on work and family units. Journal of Social Behavior and Personality, 3, 91-112.

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Jerrell, J., and Rightmyer, J. (1985). Evaluating employee assistance programs: A review of methods, outcomes, and future directions. In J. Dickman, W. Emener, and W. Hutchison (Eds.), Counseling the troubled person in industry. Springfield, IL: Charles C. Thomas. Jones, A., and Butler, M. (1980). A role transition approach to the stresses of organizationally-induced family role disruption. Journal of Marriage and the Eamily, 42, 367-376. Kazdin, A. (1980). Research design in clinical psychology. New York: Harper and Row. Kurtz, N., and Googins, B. (1979). Managing the alcoholic employee: Towards a model for supervisory intervention. Industrial Management, 21, 15-21. Kurtz, N., Googins, B., and Howard, W. (1984). Measuring the success of occupational alcoholism programs. Journal of Studies on Alcohol, 45, 33-45. Lee, S., and Rosen, E. (1984, January). Employee counseling services: Ethical dilemmas. Personnel and Guidance Journal, 276-279. Masi, D. (1984). Developing employee assistance programs. New York: American Management Association, Inc. Maxwell, M. (1960). Early identification of problem drinkers in industry. Quarterly Journal of Studies on Alcohol, 21, 655-678. McClellan, K. (1982). An overview of occupational alcoholism issues for the 80s. Journal of Drug Education, 12, 1-26. Myers, D. (1985). Employee problem prevention and counseling: A guide for professionals. Westport, CT: Quorum Books. Pfaller, J., Baumgartner, L., and Gerstein, L. (1989). The Behavioral Index of Troubled Employees (BITE): Use with female supervisors. Unpublished manuscript. Ball State University, Muncie, IN. Piliavin, J., Dovidio, J., Gaertner, S., and Clark, R., III. (1981). Emergency intervention. New York: Academic Press. Prien, E., Jones, M., Miller, L., Gulkin, R., and Sutherland, M. (1979). Mental health in organizations: Personal adjustment & constructive intervention. Chicago: Nelson-Hall. Quayle, D. (1985). American productivity: The devastating effect of alcoholism and drug abuse. In J. Dickman, W. Emener, and W. Hutchison (Eds.), Counseling the troubled person in industry. Springfield, IL: Charles C. Thomas. Roman, P. (1980). Medicalization and social control in the workplace: Prospects for the 1980's. Journal of Applied Behavioral Sciences, 16, 407-422. Roman, P. (1981). From employee alcoholism to employee assistance. Journal of Studies on Alcohol, 42, 244-272. Roman, P. (1982). Barriers to the use of constructive confrontation with employed alcoholics. Journal of Drug Issues, 12, 369-382. Roman, P., and Blum, T. (1985). The core technology of employee assistance programs. Almacan, 15, 8-12. Roman, P., and Trice, H. (1968). The sick role, labeling theory and the deviant drinker. International Journal of Social Psychiatry, 12, 245-251. Royce, J. (1981). Alcohol problems and alcoholism. New York: Free Press. Scanlon, W. (1986). Alcoholism and drug abuse in the workplace. New York: Praeger. Scher, J. (Ed.). (1973). Drug abuse in industry: Growing corporate dilemma. Springfield, IL: Charles C. Thomas.

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Schramm, C , Mandell, W., and Archer, J. (1978). Workers who drink: Their treatment in an industrial setting. Lexington, MA: Lexington Books. Shain, M., and Groeneveld, J. (1980). Employee assistance programs, philosophy, theory and practice. Lexington, MA: Lexington Books. Shain, M., Suurvali, H., and Boutilier, M. (1986). Healthier workers: Health promotion and employee assistance programs. Toronto: Lexington Books. Smart, R. (1974). Employed alcoholics treated voluntarily and under constructive coercion. Quarterly Journal of Studies on Alcohol, 35, 196-209. Sonnenstuhl, W., and Trice, H. (1986). Strategies for employee assistance programs: The crucial balance. Ithaca, NY: ILR Press. Stackel, L. (1987). EAPs in the work place. Employment Relations Today, 3, 289-294. Trice, H. (1957). Identifying the problem drinker on the job. Personnel, 34, 527-533. Trice, H. (1964). New light on identifying the alcoholic employee. Personnel, 41, 1825. Trice, H. (1980). Applied research studies: Job based alcoholism and employee assistance programs. Alcohol Health and Research World, 4, 4-16. Trice, H., and Belasco, J. (1968). Supervisory training about alcoholics and other problem employees. Quarterly Journal of Studies on Alcohol, 29, 382-399. Trice, H., and Beyer, J. (1977). Differential use of an alcoholism policy in federal organizations by skill level of employees. In C. Schramm (Ed.), Alcoholism and its treatment in industry. Baltimore, MD: Johns Hopkins University Press. Trice, H., and Beyer, J. (1979). Women employees and job-based alcoholism programs. Journal of Drug Issues, 3, 371-385. Trice, H., and Beyer, J. (1984). Work-related outcomes of the constructive-confrontation strategy in a job-based alcoholism program. Journal of Studies on Alcohol, 45, 393-404. Trice, H., and Roman, P. (1971). Constructive confrontation. Wachovia, 58, 21-24. Trice, H., and Roman, P. (1972). Spirits and demons at work: Alcohol and other drugs on the job (1st ed.). Ithaca, NY: New York State School of Industrial and Labor Relations, Cornell University. Trice, H., and Roman, P. (1978). Spirits and demons at work: Alcohol and other drugs on the job (rev. ed.). Ithaca, NY: New York State School of Industrial and Labor Relations, Cornell University. Trice, H., and Sonnenstuhl, W. (1985). Constructive confrontation and counseling. EAP Digest, 5, 31-36. Walker, K., and Shain, M. (1983). Employee assistance programming: In search of effective interventions for the problem-drinking employee. British Journal of Addiction, 78, 291-303. Walster, E., Walster, G., and Berscheid, E. (1978). Equity theory and research. Boston: Allyn and Bacon. Wilcox, J. (1985). Employee assistance programs in the federal government: Hindrances and facilitators to supervisory constructive intervention. Unpublished doctoral dissertation, George Washington University, Washington, DC. Wrich, J. (1980). The employee assistance program. Center City, MN: Hazelden Foundation. Wrich, J. (1986). The impact of substance abuse at the workplace. In H. Axel (Ed.),

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Corporate strategies for controlling substance abuse. New York: The Conference Board, Inc. Young, D., Reichman W., and Levy, M. (1987). Differential referral of women and men to employee assistance programs: The role of supervisory attitudes. Journal of Studies on Alcohol, 48, 22-28.

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15 EAPs AND EARLY INTERVENTION FOR ALCOHOL PROBLEMS AT THE WORKPLACE ANDREA FOOTE

The labels c'prevention'' researchers and "intervention" researchers have done more to confuse than to elucidate the differences between two branches of alcoholism research. The two concepts are not mutually exclusive; prevention is an intervention, and interventions are usually designed to prevent something. What, then, are the differences between the two types of research? Prevention research has sometimes been confused with epidemiology. This is clearly incorrect. Epidemiology can identify places where interventions might be developed and tested; in other words, they can set the stage for prevention research of various types. Epidemiological studies may provide hypotheses about the types of prevention programs that are needed, but they are not substitutes for studies of the prevention programs. Descriptive research which concludes that alcohol problems may be addressed by implementing Program A is insufficient. It is necessary to demonstrate how to implement Program A and to provide evidence that Program A in fact produces the desired result. These tasks are the focus of prevention/intervention research. A good example is provided in a review by D.A. Parker and G.C. Farmer of the epidemiology of alcohol abuse among employees (Parker and Farmer, 1988). The studies reviewed showed evidence that various aspects of work are related to alcohol use, abuse, and dependence. However, the studies do not provide evidence regarding what interventions might be implemented to change aspects of work in such a way as to reduce alcohol use, abuse, and dependence. This is the task of prevention/intervention research. Two variables appear to distinguish the work of preventionists and interventionists. The first is the nature of the programmatic effort. Preventionists tend to focus on primary prevention; interventionists are more interested in secondary or tertiary prevention, i.e., early identification and amelioration of existing prob-

Employee Assistance Programs

228 Table 15-1 Prevention/Intervention Paradigm

Focus of Programmatic Effort

Nature of Programmatic Primary Prevention

Effort

Secondary/Tertiary Prevention

S o c i a l or Social/organizational organizational interventions to a l t e r change environmental influences ( s t r e s s , alcohol a v a i l a b i l i t y , etc.)

Social/organizational interventions to identify and s e r v e p e o p l e a t r i s k or i n need of h e l p (EAPs, e t c . )

Individual change

Treatment/clinical interventions

Education

lems. The two groups may also differ in regard to the focus of the programmatic effort: individual versus social or organizational. Thus, preventionists may be seen as people conducting research on interventions designed to prevent incidence of alcohol problems through social or organizational changes, and interventionists as people conducting research on interventions designed to reduce the severity of alcohol problems through individual changes. This may lead to an assumption that primary prevention is focused on social or organizational changes and that secondary and tertiary prevention or intervention is focused on individual changes. The paradigm in Table 15-1 suggests, in contrast, that the nature of effort and the focus of effort are independent variables. Primary prevention at the organizational level includes interventions intended to alter environmental influences on drinking behavior. Primary prevention at the individual level might include certain kinds of educational interventions. Secondary and tertiary prevention at the organizational level might target specific organizational structures or behaviors that contribute to continued misuse of alcohol or organizational structures or behaviors that encourage and support various types of assistance to people at risk or in need. In all cells, of course, the ultimate objective is individual change. Efforts directed to organizational or social change merely have additional intermediate steps; they attempt to alter individual behavior by altering organizational behavior. Viewed in that way, social change interventions are more devious methods of social control; they attempt to alter individual behavior without the individuals' awareness of the attempt. EAPs AS O R G A N I Z A T I O N A L C H A N G E S AND C H A N G E AGENTS Employee assistance programs (EAPs) may appear to be misplaced in the paradigm in Table 1 5 - 1 , since they seem to be focused on individual change.

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229

EAP staff members are certainly involved at a clinical level, trying to get clients to take certain actions. However, employee assistance programs are themselves organizational changes. EAPs were developed as an alternative means for work organizations to deal with troubled employees, replacing such organizational responses as covering up for the employee, thus enabling continued alcoholic behavior, or addressing the problem only with discipline or dismissal of the employee. EAPs offer a constructive alternative for the work organization. The implementation of an EAP is an organizational change. Once implemented, EAPs may act as change agents within the work organization, through consultation with supervisors and other organizational units. The research on EAPs reflects this focus on organizational issues. EAP research has addressed such questions as "how do EAPs vary in their structure and functions" (Roman, 1988), "what factors affect supervisory use of an EAP" (Googins and Kurtz, 1981), "how are EAPs staffed" (Blum, 1988; Foote, Erfurt, and Austin, 1980), "what EAP procedures are associated with reduced relapse rates" (my own work in process, with J.C. Erfurt), "what are the work-related outcomes of constructive confrontation" (Trice and Beyer, 1984), and "how do you get an organization to adopt and implement an EAP" (Beyer and Trice, 1978). The focus of EAP research has not been on how to get alcoholic clients to change their behavior, but how to get organizations and organizational units to change their behavior. Certainly the ultimate objective is the recovery of alcoholic (and other) clients, just as the ultimate objective of primary prevention efforts is reduced incidence of alcohol problems. But the immediate objective is organizational change. EAPs AND EARLY INTERVENTION Employee assistance programs are frequently described as vehicles for early intervention. It is argued that the workplace, and specifically the supervisor, is in a position to identify employee problems through deterioration in work performance and to confront the employee, break through denial, and force the employee to take action before the employee otherwise would have done (Wrich, 1980; Schramm, Mandell, and Archer, 1978). The available research raises questions, however, about the degree to which supervisors actually do identify early cases through work performance problems. Interviews with supervisors suggest that clear work performance deficits are seldom identified until the client is in the late stage, and that supervisors frequently use other signs of drinking to help identify employees with alcohol problems (Maxwell, 1972; Kurtz, 1980; Reichman, Young, and Gracin, 1988). A recently completed data collection provides some illustrative information. The study involved 444 EAP clients in a large manufacturing plant (about 9,500 employees). The EAP had been in existence for about 10 years when the study was conducted, and it was staffed by three full-time people.

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230

Table 15-2 Stage of Problem by Type of Problem Stage of Problem

Type of Problem Alcohol

Other Drug

Other

Chronic/late

69%

85%

74%

Middle

30

13

22

1

2

4

Early Total

100%

100%

100%

(N)

(205)

(120)

(113)

NOTE:

Stage of problem was missing for 6 c l i e n t s .

Table 15-2 shows the EAP counselors' assessment of the clients' problem stage, by type of problem. While the EAP staff members saw about 5 percent of the company's employees during the study year, few of the clients (only 7 of 444) were classed as in the early stages of their problem, regardless of the type of problem, and only a minority were in the middle stages. Other data from the study tend to validate the judgment of the EAP counselors; clients judged as late stage were more often absent and sick then those judged as middle stage. Thus, in this particular group of clients there was very little early intervention. This leads us to ask how these clients were identified. Note that this is an organizational question: what structures and procedures were put in place by the EAP to produce a client flow? The usual way of examining this question is to look at the sources of referral to the EAP. Forty-five percent of the 444 clients in this study reported themselves as self-referred, 24 percent were referred by the plant medical department, 11 percent were referred by a union representative, and 10 percent were referred by a supervisor. (The remaining 10 percent were referred by a variety of other sources.) If the supervisors are trained to make EAP referrals when there are significant work performance problems, this profile of referral sources suggests a client group with few work performance problems, which seems unlikely given that the majority were recorded as having late-stage substance abuse or other problems. Table 15-3 provides a cross-tabulation of source of referral by type of work performance problem reported by the client. This table shows that most of the EAP clients reported work performance problems (only 24 percent did not report such a problem). Yet almost half of the clients were self-referred, and few were referred by their supervisor. Furthermore, there was no type of work performance problem for which supervisors accounted for the majority source of referral. What do these data tell us about work performance deterioration as a mech-

EAPs a n d Early Intervention at the Workplace

231

Table 15-3 Source of Referral by Work Performance Problem

Reported Work P e r f . Problem:

Self

Attendance

42%

Qual./Quan.

Source of R e f e r r a l : Union

Medical

Other

14

7

26

11

100%

(139)

10%

10

30

40

10

100%

(10)

Safety

32%

11

26

29

2

100%

(65)

Work w/ others

23%

14

27

36

0

100%

(22)

Other

47%

8

8

23

14

100%

(99)

None

64%

4

5

16

11

100%

(107)

Total

45%

10

11

24

10

100%

(442)

NOTE:

Super.

Reported work performance problem was m i s s i n g for 2 c l i e n t s .

anism for early intervention? First, the data suggest that the EAP model of supervisory confrontation and referral is not well implemented in this organization. The case-finding procedures in place are identifying primarily people with late-stage problems, but these people are not being identified by those charged with oversight of work performance. Addressing this issue within this company would require an organizational intervention. When an EAP examines its data in this way, it becomes possible to develop recommendations for certain types of organizational changes. Data from this EAP suggest that many supervisors are continuing a practice of coverup for poor performers. The EAP may recommend procedures for assessing why this is so, leading perhaps to improved supervisory training or methods for holding supervisors accountable for performance of subordinates. Such changes could result in improved secondary or tertiary prevention. It is possible, of course, that some of the so-called self-referrals in this EAP caseload were actually referred by their supervisor, since supervisors were not asked to inform the EAP when they made a referral. However, it seems unlikely that many clients would hide the fact that they were referred by their supervisor but disclose their work performance difficulties. In any case, it is evident that the case-finding procedures implemented in this company were not finding clients at an early stage. The example leads us again to consider whether it is realistic to assume that EAPs can identify early-stage clients. In the program studied, the EAP had apparently not succeeded in training supervisors to refer middle-stage or even

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Employee Assistance Programs

late-stage clients, and a variety of other units within the worksite were making substantial numbers of referrals to the EAP, notably the medical department. Given the apparent difficulties in getting supervisors to refer employees with deteriorated work performance, it seems even less likely that supervisors can be trained to refer employees whose work performance is still marginally acceptable. Even more to the point, it is likely that most people with early-stage problems do not yet evidence measurable work performance deficits. The concept of early intervention by EAPs should probably be interpreted to mean earlier than would otherwise have occurred, rather than intervention at an early stage in the problem's development. POTENTIAL FOR EARLY-STAGE INTERVENTION AT THE WORKSITE Employee assistance programs using identification based on work performance do not appear to be useful vehicles for early identification of alcohol abuse or alcoholism because they rely on work performance deficits, which probably do not occur until the employees reach the middle or even the late stages of the problem. Are there other types of EAPs or other workplace services that can address early intervention? Five possibilities may be considered. Educational Programs Using educational programs, linked with program promotion, to attract selfreferrals to the EAP define the EAP as an employee benefit, rather than an arm of the organization. Most EAPs include aspects of this model, and many believe that they are getting earlier intervention with self-referrals (Shain and Groeneveld, 1980). However there is little evidence to indicate that self-referrals are people with early-stage problems that would develop into more severe problems without the EAP. While self-referrals do tend to include more people without work performance problems, as compared with referrals from other sources, studies that could show that EAP services prevent further deterioration in these people have not been done. It is quite possible that many self-referrals are people who would have dealt with their problems in the absence of the EAP, and that the problems would not have developed to more severe stages. Expansion of EAP Services to Nonsubstance-Abuse Problems Some EAPs have argued that services to clients with family and marital problems, emotional problems, or "life adjustment" problems are early intervention for alcohol problems. While epidemiological studies show various relationships between alcohol-related measures and various measures of stress, there is little evidence to show that specific interventions to reduce the stress

EAPs and Early Intervention at the Workplace

233

produce reductions in the alcohol measures. Nor is intervention with alcohol abuse necessarily early intervention for alcoholism. EAPs have necessarily had to develop the capability of responding to employees who have this broad array of problems, minimally by providing an appropriate referral resource and sufficient skills to decide what type of referral is needed. In many locations the EAP is the only resource available to the employees within the context of the worksite; most work locations have no medical resources on site. And in some locations that do have medical departments, the department is so identified with management functions (i.e., certification of fitness for work) that some employees are reluctant to use the department staff to address personal needs. In other locations, the EAP and medical staff may share in providing counseling and referral to employees with personal problems. But there is no evidence that EAP intervention with these types of problems prevents alcohol abuse or alcoholism. Identification Based on Physiological Signs of Alcohol Problems Interviews with supervisors indicate that they do in fact use such signs in deciding when to confront an employee (Maxwell, 1972; Kurtz, 1980). However, the EAP field has largely discouraged this model because it is seen as being inappropriately intrusive into the private lives of employees and it requires what amounts to a clinical evaluation of employees by nonclinicians. Drug screening is a similar strategy, which relies on properly trained technicians (not supervisors) to make the observations (tests). The issue of intrusion into private lives remains, however. This issue aside, the strategy provides a method for identifying users, but no clear approach for intervention. Similar concerns arise in considering the use of genetic screening to identify people at risk of developing alcohol problems. An appropriate intervention with people so identified has not been developed. Management Consultation EAP consultation with management may occur in four areas. (1) EAPs provide consultation to individual supervisors about how to deal with problem subordinates. This can result in the assistance of many employees through the presence of an EAP, without their ever having become EAP clients. (After supervisory confrontation the clients take action on their own to address their problem, without going to the EAP.) This is clearly an organizational intervention, utilizing the EAP to make changes in organizational behavior of supervisors vis-a-vis employees. It may improve the case-finding process, which may result in earlier (but probably not early) intervention. (2) EAP consultation may also produce general improvement in supervisory practice, which may reduce work stress for some employees. This may have implications for both early intervention and primary prevention, but evidence is needed to identify precisely what types of

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Employee Assistance Programs

problems are being prevented. (3) EAPs sometimes identify other organizational procedures or structures that are causing worker stress and make recommendations for changes. (4) EAPs sometimes provide assistance in identifying and dealing with transitional stresses resulting from major organizational changes. While EAP staff report varying degrees of involvement in all of these areas, evidence is lacking regarding their impact as prevention strategies. Furthermore, there are few estimates of how much change a very effective intervention of this kind can be expected to produce. One such set of estimates may be derived from the Parker and Farmer study (1988). They reported a series of regression equations predicting various types of drinking variables, using a combination of work-related and demographic variables as predictors. The proportion of variance in the drinking measures accounted for by this group of predictor variables ranged from 6 to 20 percent, but demographic variables contributed a significant amount of this variance. If an intervention were implemented that successfully removed all of the work-related contributors to drinking (a difficult task), most of the drinking behaviors would remain. Nevertheless, such an intervention might be worth implementing, depending on how costly it was in relation to its effectiveness. Voluntary Participation in Wellness Programs Early identification through voluntary participation in wellness programs (e.g., blood pressure screening and follow-up) or other health-related programs may be a promising model, especially because of the relationship between heavy drinking and high blood pressure (Dyer et al., 1977; Klatsky et al., 1977). Little work has been done, however, on how wellness programs might effectively raise and address potential drinking problems with their clients without risking loss of the client from the program. CONCLUSIONS Existing research suggests that the EAP model of early identification based on job performance problems does not identify people with early-stage alcoholism. Alcoholism in the early stages does not appear to produce job performance deficits sufficient to cause supervisory confrontation and referral. Is it realistic or reasonable to expect early identification of alcohol problems by EAPs? That is, are there models available that would result in early identification, and are they models that can appropriately be adopted by EAPs? Answers to these questions are not clear. Comparative or controlled research studies on suggested models have not been conducted. Like primary prevention, early intervention must be measured by what does not subsequently happen, and this requires research designs of the kind that are difficult to implement, i.e., designs that compare incidence of chronic problems over time across similar groups that do and do not use the early intervention strategy.

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235

All such research must include measures of how effective the intervention was at preventing the targeted problem (primary, secondary, or tertiary). Interventions that reduce organizational stress, for example, cannot be assumed to have reduced the incidence of alcohol problems in the absence of any data. Of the strategies for early intervention reviewed above, screening for signs of alcohol use or genetic susceptibility and screening for related health problems are likely to identify early-stage alcohol problems, but neither has a well-developed intervention design. The effectiveness of increased self-referrals as a method for producing early intervention (the first strategy discussed) is worth studying, particularly because it is so widely believed to be valid. The use of services for problems other than substance abuse may produce secondary and tertiary prevention for those problems and the strategy may also serve as primary prevention for alcohol misuse. Finally, management consultation may produce primary prevention for stress-related problems, as well as earlier supervisory intervention.

NOTE Support from Grant No. R01-AA-06567 from the National Institute on Alcohol Abuse and Alcoholism is gratefully acknowledged.

REFERENCES Beyer, J.M., and Trice, H.M. (1978). Implementing change: Alcoholism policies in work organizations. New York: The Free Press. Blum, T.C. (1988). New occupations and the division of labor in workplace alcoholism programs. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6). New York: Plenum Press. Dyer, A.R., Stamler, J., Paul, O., Berkson, D.M., Lepper, M.H., McKean, H., Shekelle, R.B., Lindberg, H.A., and Garside, D. (1977). Alcohol consumption, cardiovascular risk factors, and mortality in two Chicago epidemiologic studies. Circulation, 56 (6), 1067-1074. Foote, A., and Erfurt, J.C. (1988). Effects of EAP follow-up on prevention of relapse among substance abuse clients. Unpublished manuscript, University of Michigan, Ann Arbor, MI. Foote, A., Erfurt, J . C , and Austin, R. (1980). Staffing occupational employee assistance programs: The General Motors experience. Alcohol Health and Research World, 4 (3), 22-31. Googins, B., and Kurtz, N.R. (1981). Discriminating participating and nonparticipating supervisors in occupational alcoholism programs. Journal of Drug Issues, 11 (2), 199-216. Klatsky, A.L., Friedman, G.D., Siegelaub, A.B., and Gerard, M.J. (1977). Alcohol consumption and blood pressure. New England Journal of Medicine, 296, 1194— 1200. Kurtz, N.R. (1980). Dynamics of the identification and referral process in work orga-

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nizations. In Occupational alcoholism: A review of research issues (Monograph No. 8). Washington, DC: Government Printing Office. Maxwell, M.A. (1972). Alcoholic employees—Behavior changes and occupational alcoholism programs. Alcoholism 2, 174-180. Parker, D.A., and Farmer, G.C. (1988). The epidemiology of alcohol abuse among employed men and women. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6). New York: Plenum Press. Reichman, W., Young, D.W., and Gracin, L. (1988). Identification of alcoholics in the workplace. In M. Galenter (Ed.), Recent developments in alcoholism (Vol. 6). New York: Plenum Press. Roman, P.M. (1988). Growth and transformation in workplace alcoholism programming. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6). New York: Plenum Press. Schramm, C.J., Mandell, W., and Archer, J. (1978). Workers who drink. Lexington, MA: Lexington Books. Shain, M., and Groene veld, J. (1980). Employee-assistance programs. Lexington, MA: Lexington Books. Trice, H.M., and Beyer, J.M. (1984). Work-related outcomes of constructive confrontation strategies in a job-based alcoholism program. Journal of Studies on Alcohol, 45, 393-404. Wrich, J.T. (1980). The employee assistance program. Center City, MN: Hazelden.

16 HELP-SEEKING AND HELPING PROCESSES WITHIN THE WORKPLACE: ASSISTING ALCOHOLIC AND OTHER TROUBLED EMPLOYEES WILLIAM J . SONNENSTUHL

Evaluation research demonstrates that the dual strategy of employee assistance programs (EAPs)—constructive confrontation and counseling—is a potent mechanism for assisting alcoholic and other troubled employees (Trice and Beyer, 1984b; Sonnenstuhl and Trice, 1986). Unfortunately, a great deal of mystery surrounds this dual strategy because the concept of constructive confrontation has become reified and the process of counseling has been cloaked in mystery. As such, constructive confrontation has become equated in the minds of many employee assistance workers with what supervisors do to motivate employees to go to treatment and has become divorced from the help-seeking process of advice giving and receiving of which it is a part. Similarly, the counseling side of EAP work remains to a great extent an impenetrable black box shrouded in pleas of confidentiality. Consequently, relatively little is known about how EAPs actually help employees. This chapter attempts to demystify the subject by reporting on ethographic research examining the help-seeking and helping processes which make up EAP work. Briefly, our research suggests that the EAP's help-seeking and helping processes work differently for alcoholic and other troubled employees because alcohol problems and other emotional disorders exist within different social contexts. According to A.V. Horwitz (1982), the primary task of counseling is to provide sufferers and those around them with the means to grasp the nature of their distress, which is possible only if therapists are able to incorporate clients' experiences within a culturally shared universe of meaning. Clients who share a communal existence—those who live in groups marked by many interlocking ties between members, strong group cohesion, and an emphasis upon group rather than individual welfare—respond to communal forms of therapy, which are highly ritualistic and promote conformity to group norms as a means

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of cure. When the social structure becomes individualistic, as in modern Western societies, therapy emphasizes individual motivation, involves the promotion of self-awareness and individual autonomy, and becomes a relationship solely between the therapist and the client. Alcohol problems exist within a communal context. Individuals receive social support for their drinking behavior, and individuals with developing alcohol problems generally seek out drinking groups supportive of their behavior (Trice, 1966, 1984). Consequently, employees with alcohol problems will not seek help unless these social supports can be overcome and they recognize that their drinking behavior is a problem. As a result, unsolicited comments from supervisors and co-workers become instrumental in motivating employees with alcohol problems to seek help. Once in the EAP, effective therapy reflects the communal context of alcohol problems. Help consists of replacing the community of drinkers with the communal support of Alcoholics Anonymous (AA). In this instance, communal therapy consists of accepting the AA ideology: alcoholism is a disease; alcoholics are powerless over alcohol; and sobriety is possible only when one turns oneself over to a higher power (e.g., the AA group) and strictly adheres to the Twelve Steps. In contrast, employees' other emotional troubles exist within an individual context—a social existence marked by numerous and interchangeable, but superficial, social relationships. Within such a context, individuals seek advice from others about their unique problems and learn that those problems are amenable to individualized forms of therapy. Essentially, they learn a mental health ideology that emphasizes that "healthy" personalities are self-fulfilled, spontaneous, free, and autonomous, and they learn that these qualities can be learned through the therapeutic process. In the United States these beliefs are heavily concentrated among the educated middle class. Individuals from this class learn the ideology, take it for granted, and use their social networks as sounding boards to refute or confirm their need for treatment. Individuals from lower class backgrounds, on the other hand, because such knowledge is not naturally part of their networks, are likely to have these beliefs thrust upon them in the form of unsolicited advice. Within the workplace, social support for going to the EAP often comes in the form of both solicited and unsolicited advice, whereby the individual learns that his or her problems can be helped by counseling. Once in the EAP, therapy reflects their individual existence and the mental health ideology. Unlike communal therapy, it is not ritualized but it emphasizes individual therapeutic goals, rather than conformity to group norms. METHODS In order to understand how employees decide to seek help and how employee assistance counselors attempt to help them, we have been observing and interviewing employees and employee assistance counselors in four different programs. The first program is a corporate in-house EAP, staffed by six full- and

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part-time clinical psychologists who are skilled in cognitive behavioral therapy. During the period of data collection, from 1980 to 1981, they saw clients in order to assess their troubles and either to treat them with short-term techniques or to refer them out to community resources for more intensive treatment. The second program is a union in-house program, staffed by two alcoholism counselors who are aided in their work by a network of union members who are also Alcoholics Anonymous members, the Ten Percenters. During the period of data collection, from 1984 to 1985, the counselors and the AAs actively confronted co-workers, both on and off the job, about problem drinking and other personal troubles and attempted to help them. In the case of alcoholic employees, help consisted of involving them in the network as well as, in some instances, referring them to treatment in an inpatient alcoholism rehabilitation program (see Sonnenstuhl, 1986; Sonnenstuhl and Trice, 1987). The third and fourth programs are both located in nonprofit social service agencies, and both programs have grown steadily since we first started studying them in 1985. The third program is located within a family services agency. In 1985, it consisted of two social workers, one psychologist, and one pastoral counselor; today, it has six full-time staff and two part-time counselors. The fourth program is a subsidiary of Catholic Charities. In 1985, the program consisted of the director and one counselor, both of whom were community psychologists with backgrounds in alcoholism counseling; today, the program is staffed by five full- and part-time counselors with backgrounds in psychology, social work, probation, and substance abuse. Both programs perform an assessment of employees' problems and provide either short-term counseling or referral to a community resource. The Family Service program provides up to eight free counseling sessions per year to employees before referring them to community resources. Previously, the Catholic Charities program offered an open-ended policy on short-term counseling, often seeing some clients for a year or more; however, they have begun to restrict their EAP work to four sessions during which counselors are expected to assess employees' problems and then refer them to community resources. Data collection and analysis are still occurring within these two programs; consequently, the following remarks should be regarded as speculative and emergent rather than as definitive statements about the help-seeking and helping processes within EAPs. In each of the programs, we have utilized a variety of qualitative field methods—primarily observation and in-depth interviews—in order to develop an accurate picture of what brings employees to EAPs and what happens to them once they arrive there. In each of the programs, we have observed the counselors assessing employees' troubles, counseling them, and making referrals to community resources. Observations of such counselor-employee interactions are always with the consent of both the counselor and employee. In addition, we have formally and informally interviewed both counselors and employees about their experiences and have participated in a variety of other EAP-related activities such as sitting in on staff meetings and clinical review sessions, observing

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supervisory training and employee education sessions, attending meetings of Alcoholics Anonymous and of the Association of Labor and Management Administrators and Consultants on Alcoholism (ALMACA) with EAP staff, and visiting employees and their families in either their homes or at rehabilitation facilities. In going about these tasks, we have kept detailed notes of our observations and conversations. During interviews, we used tape recorders. Interviews usually occurred after we had developed some insight into the help-seeking or helping process and were able to query the employees and counselors for more detailed explanations of what was taking place. These interviews were then transcribed for analysis. From these interviews and observations, we have been slowly and painstakingly piecing together a picture of the help-seeking processes that bring employees to the EAPs and the helping processes that occur there. In analyzing the data, we are using the constant comparative method (Glaser and Strauss, 1967; Glaser, 1978; Strauss, 1987; Charmaz, 1983; Lester and Hadden, 1980), which is designed to develop rich descriptions of a social phenomenon, to make discoveries about it, and to generate hypotheses and theory about it. The constant comparative method is not a technique for testing theory. Consequently, our intention is simply to describe in as much detail as possible what actually motivates employees to go to the EAP and what happens to them once they arrive there so that we can construct a set of grounded hypotheses to explain these social processes. At a later date, we plan to test these hypotheses by using rigorous quantitative methods. Meanwhile, the insights generated from our ethnographic work may be helpful to employee assistance workers as they set about their tasks. Briefly, the constant comparative method works as follows.1 First guiding questions are asked: What motivates alcoholic and other troubled employees to use the EAP and what happens to them after they arrive there? While we observe, interview, and write up our field notes, we look for incidents that bear upon these questions. Incidents include interviews with employees, co-workers, or EAP staff as well as observations of interactions between these individuals. In comparing one incident with another, salient categories begin to emerge. For instance, conversations with co-workers, supervisors, family members, or EAP staff members frequently explain why alcoholic and other troubled employees use the EAP. Observations in the field confirm that such conversations do occur. Conversations, then, can be assumed to be an important category for understanding how EAPs work. It is important to know, however, about the properties of conversations. What is the content of conversations? How does the content vary with who is conversing? Who initiates the conversations? Under what conditions do the conversations occur? Depending upon whether the employee is alcoholic or troubled, how do conversations vary? What is it about conversations that prompts employees to use an EAP? In pursuing the answers to such questions, one continuously collects more data and compares incidents. Slowly, a detailed description of conversations emerges, and hypotheses about when they occur and how they prompt employees to use the EAP are generated. When

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hypotheses are generated, they are provisionally tested by theoretical sampling. For example, if it is hypothesized that X type of conversations occur in union EAPs, the proposition may be tested by observing whether they also occur in management or in joint labor-management EAPs. In this way, generated hypotheses are continuously modified to fit the empirical data. For this reason, theory generated by the constant comparative method is referred to as "grounded theory"; that is, it is grounded in empirical observations of the phenomenon rather than being inferred from what one believes or thinks about it. HELP-SEEKING AND SOCIAL SUPPORT Within employee assistance circles, terms such as "supervisory referral" and "self-referral" are often used to explain how employees arrive at the program seeking help. In particular, use of the term self-referral has ballooned to the point where it is now the predominant explanation of employees' help-seeking behavior used by employee assistance workers (Roman, 1988). Such terms, however, do not accurately reflect the complexity of employees' help-seeking behavior because they are processing stereotypes (Hawkins andTiedeman, 1975), simplified images used by employee assistance workers to standardize decisions about what to do with employees who come to the program. Generally, supervisory referral indicates that the supervisor has recommended that the employee use the program to correct his or her unsatisfactory performance and that the employee assistance counselor must give the supervisor some feedback on the case. In contrast, self-referral indicates that the employee has voluntarily sought help and that the employee assistance counselor is under no obligation to give the employees' employer any feedback. (For a detailed discussion of referral terms as processing stereotypes, see Sonnenstuhl, Staudenmeier, and Trice, 1988; and Trice and Sonnenstuhl, 1988.) Several strands of data indicate that these terms are processing stereotypes rather than accurate reflections of employees' help-seeking behavior. First, although all four of our EAP research sites use such terms, none have explicit guidelines instructing counselors in how to use them when indicating the source of referral. This was dramatically highlighted at a staff meeting in which the counselors were discussing the statistical report that they give to their clients every six months. One counselor inquired how his colleagues determined the source of referral and then stated that he checked "supervisory referral" only when the employer "mandated" that the employee go to the EAP. That is, the employee was told that he or she must go to the EAP for an assessment and that he or she did not have any choice. Another counselor indicated that this was correct but that only one of their contracts had such a mandated referral and that these were very rare. Still another stated that he had never checked the category unless the director explicitly instructed him to do so. Yet another stated she used the category if the employee indicated that his or her supervisor had suggested that he or she use the program. All agreed that use of the category was unclear

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and that they were uncomfortable with it; all preferred to see employees who came voluntarily. Additionally, observations of the counselors conducting intakes illustrated the perfunctory nature of indicating the source of referral. When asked how they came to the program or when asked the source of referral and given a choice of answering self, family, friend, or supervisor, most employees simply responded that they came on their own. Rarely were such responses probed for further meaning. In one instance, when an employee responded that she came at the suggestion of her supervisor, the counselor probed further and solicited the comment from the woman that she had come voluntarily. The counselor then corrected the woman and told her that she was actually a self-referral. In another instance, the intake elicited a response of self-referral, but the counselor discovered, several sessions later, that the employee's supervisor had confronted him about his performance and had referred him. The counselor made no attempt to change the source of referral. Finally, in-depth interviews with employees labeled "self-referrals" indicated a diversity of motivations for seeking help (Sonnenstuhl, 1982, 1986). Motivations included employees' conversations with family, friends, co-workers, and supervisors who recommended that they seek help from the EAP for their troubles as well as learned cultural rationales for using medical services. In one instance, an employee with a 30-year history of abusive and alcoholic drinking was sent home by his supervisor because he was drunk on the job. The next day he reported to the EAP as a "voluntary referral," and he was duly recorded as a self-referral even though he realized that he "more or less got kicked out of [his] job" (Sonnenstuhl, 1986, 94).

FACTORS AFFECTING HELP-SEEKING If referral categories are processing stereotypes, how do employees seek help from the EAP? They do so within a complex social network of advice giving and receiving (Sonnenstuhl, 1982). Supervisors are but one of the actors in this network; other actors include the employee's colleagues and co-workers, family members, and friends. Within this network of work and nonwork relationships, employees may either solicit advice or receive unsolicited advice about their problems. As a result of these interactions, employees learn that they have troubles that require professional help and that the EAP can provide it. In an ideal world, everyone would be able to recognize one's own faults and take action without either solicited or unsolicited advice from anyone. However, few people arrive at mental health services without receiving some advice (Cockerham, 1981; Horwitz, 1977; Veroff et al., 1981). For instance, according to C. Kadushin (1969), from 80 to 90 percent engage in conversations about their problems before they go to a therapist. Of these, 20 percent receive only un-

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solicited comments; 40 percent receive only solicited comments; and the remaining 40 percent receive both types. A variety of factors affects whether employees are likely to receive advice from their networks. A primary consideration is the visibility of the problem. Some problems such as family troubles and stress reactions are generally invisible to other people; consequently, employees with such problems are likely to receive few unsolicited comments and mostly solicited advice from others. More visible problems, such as drunken comportment and depression, on the other hand, are likely to draw more unsolicited comments because they are visible and may disrupt ongoing social relations. One factor affecting whether employees will received unsolicited comments about visible problems is tolerance (Lemert, 1951). Some members of an employee's social network are simply more tolerant than others of disruptive behaviors. For instance, supervisors and co-workers who work closely with an employee and depend upon his or her output in order to complete their own work are likely to be less tolerant than other employees who do not have to work directly with the troubled employee. Similarly, family and friends may be more tolerant than colleagues and may even come to see the disruptive behavior as "normal" because of loyalty (e.g., Jackson, 1954; Yarrow et al., 1955). Within American culture, there is a natural reluctance for people to comment upon someone else's business (Emerson, 1970). Americans tend to believe that it is unfair or unkind to do so and that correcting such problems is the job of the police, psychiatrists, or some other specialized occupation (Trice and Roman, 1978). In addition, many fear the boomerang effect, whereby the accused turns the tables and gives the accusers unsolicited advice about their own behavior (Trice and Roman, 1978). Although most members of an employee's network are under no obligation to intercede when the employee's behavior is disruptive, supervisors are obligated to do so when the behavior adversely affects job performance. Similarly, occupational colleagues such as doctors or lawyers are under some obligation when a colleague's behavior would cause harm to clients or embarrass the profession (Bissell and Haberman, 1984). Reactions are also contingent upon the extent of the network and the social distance between the employee and network members. Employees with few contacts either inside or outside the workplace are likely to receive fewer comments of either type than those with more extensive contacts. Either very close or very distant acquaintances are candidates for an employee's referral system; "medium acquaintances" are not. The employee may solicit or receive advice from a distant contact because both parties feel free to engage in the exchange owing to the protection of social distance and impersonality. Or the employee may solicit or receive advice from a very close friend; the openness in this case stems from the trust and concern implicit in friendship. Those who stand midway between passing acquaintanceship and friendship are ruled out because they are neither far enough away to be rendered safe by impersonality nor close enough

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to warrant assumptions of trust and confidentiality. Consequently, employees are unlikely to solicit or receive advice from the neighbors to whom they nod greetings twice a week or from the uninteresting work associate; socially, they occupy the unsafe middle ground. Finally, employees' predisposition to seek advice affects the help-seeking process. Either a high or low predisposition to recognize problems leads to conversations with laymen about one's problems (Kadushin, 1969, 177-78). Employees may be highly predisposed because they are knowledgeable about mental health problems and believe that seeking help will not stigmatize them (e.g., Veroff et al., 1981). Women, for instance, are more predisposed to talk about their problems and to seek advice than men are (Horwitz, 1977). High predisposition to discuss one's problems leads employees to solicit comments from others, which generally provides a function of social support. If the others are knowledgeable about mental health problems and believe that the employee could be helped, they are likely to direct them to the EAP or some other agency for help. If they are not knowledgeable about such problems or do not believe that the employee's problem requires professional help, social support will take the form of attempts to convince the employee that he or she is okay and an admonishment to quit worrying. Low predisposition to discuss one's problems, particularly when accompanied by behavior that disrupts ongoing social relations, leads to unsolicited comments which generally provide a social control function (Horwitz, 1977). Employees may not be predisposed to talking about their problems because they are not knowledgeable about mental health problems and have never learned to talk about them or because they are knowledgeable about them and believe that if others discover that they may have such difficulties, they will be stigmatized. Consequently, employees may be barraged with nothing but unsolicited comments which (1) continue indefinitely without any effect, (2) cease when they are seen to fall on deaf ears or when the behavior comes to be accepted as a permanent eccentricity or when the behavior stops, (3) precipitate a contact with the EAP or some other mental health specialist. Employees may voluntarily contact the EAP or mental health specialist because they may simply want to avoid further harassment and prove their detractors wrong or because they have become convinced that something is wrong. In some cases, the unsolicited comments will lead employees to actively seek the advice of others for further clarification. Conversely, solicited comments may also free others to give employees unsolicited remarks, suggestions, and evaluations. Supervisors give both solicited and unsolicited advice. Employees' supervisors solicit advice when they feel a close friendship with them. More commonly, however, supervisors find themselves in the role of providing unsolicited advice because they are generally perceived as inhabiting the unsafe middle ground between friendship and passing acquaintanceship. Constructive confrontation is designed to ensure that supervisors provide employees with unsolicited comments in a noncoercive manner (Trice and Roman,

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1978; Sonnenstuhl et al., 1987). Accordingly, supervisors monitor employee job performance to detect unsatisfactory performance. When that occurs, they take corrective actions by discussing the performance problems with them, coaching them on how to improve, urging them to use the EAP's counseling services if personal problems are adversely affecting them, and, at the same time, emphasizing to them the consequences of continued poor performance. Constructive confrontation proceeds in progressive stages; at each step of the process, employees choose whether to seek help from the EAP, manage their troubles on their own, or suffer the social consequences of their actions. Within this framework, troubles are pragmatically defined within the context of the workplace, employees are given an opportunity to change their behavior with their own resources, and individuals are kept within the work group where they can receive continued social support for changing their behavior. This avoids coercing employees into treatment while simultaneously motivating them, via progressive sanctions, to do something about the personal problems that may underlie their unsatisfactory performance. Likewise, peers give both solicited and unsolicited comments to employees. For instance, in the corporate program, we found that employees sought advice from trusted co-workers whom they regarded as friends (Sonnenstuhl, 1982, 1986). From their friends, they sought advice about their problems (e.g., Is it "normal"?; What should I do?; Do you know anyone else with such problems?) and information about the corporate program. Co-workers' reactions to such inquiries were cited by the employee as important reasons for coming to the EAP. Within the union program, peers practiced their own version of constructive confrontation (Sonnenstuhl and Trice, 1987). Drawing upon observations of their co-workers and gossip about who is in trouble with their drinking, the counselors and union members in the AA network confront their co-workers by telling them that they are valued union members, that they suffer from an illness, that recovery and a joyous life is possible without alcohol, and that the network members are ready to help. In addition, they show them how alcohol is ruining their lives (e.g., physical illness, family difficulties, inability to work), and they emphasize that continued drinking will ultimately lead to a complete loss of work and, eventually, death. Such unsolicited advice was instrumental in motivating the problem drinkers to change their behavior and in motivating alcoholic peers to join the AA network. (See Bissell and Haberman, 1984, for a discussion of peer confrontation in professional groups.) At the same time, employees also solicited advice and received unsolicited comments from family and friends outside the workplace. Apparently, few employees reach the EAP without either receiving some solicited or unsolicited advice from others. Referral to the EAP, however, it should be remembered, is only one possible outcome of the interactions between the employees and their social networks. Another outcome, one that may be far more frequent than referral to professionals, is that employees learn to manage their problems with the support of their network and without any help from professionals.

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STAGES IN HELP SEEKING In deciding to seek help from the EAP, employees progress through three stages: containment, triggers to action, and lingering concerns (Sonnenstuhl, 1982, 1986). Progression through these stages may vary according to the degree of stigma employees attach to specific problems. For instance, there currently appears to be little stigma attached to seeking help for family problems. Consequently, employees seem to be relatively willing to solicit advice from colleagues and friends on such concerns as providing day care for their children or learning to be a better parent or spouse. In contrast, highly stigmatized problems such as alcoholism and depression are characterized by high levels of denial. Such troubled employees, in order to preserve their sense of self, generally do not seek advice from others and become the targets of unsolicited comments when their disruptive behavior exceeds the tolerance levels of others. Employees with highly stigmatized problems, then, are more likely than those with less stigmatized ones to become the targets of unsolicited advice. We hypothesize that employees go to the EAP when containment breaks down and they become convinced that they can no longer manage their problems without professional help. For employees with highly stigmatized problems, the accumulation of unsolicited advice is crucial to breaking through the containment stage and triggering them to seek help. Conversely, employees who find that they can manage their problems themselves will not seek professional help, either from the EAP or some other source. In the containment phase, employees are aware that they have problems and attempt to manage them so that they do not disrupt ongoing social relationships. Across the four research sites, there appears to be a great deal of similarity in employees' help-seeking behavior for low-stigma problems. When employees first become aware that they possess a problem with low-stigma potential, they may simply do nothing, hoping that, with time, the trouble will resolve itself. Some may conceal the problem from their family and friends fearing, rightly or wrongly, that, if they knew about it, they would be unduly concerned or think less of them for it. If employees are unable to conceal the problem from others, they may selectively tell close friends about it in order to solicit their support and advice. On one hand, they hope that friends and close colleagues will reassure them that it is nothing and that it will soon pass; on the other hand, they seek their advice, often home remedies or folk wisdom, about how to manage the problem. In some instances, they are encouraged to seek help from professional sources (e.g., clergy, doctors), only to experience failure. When such professional advice fails, they again seek wisdom and support from their network of friends. Although it is more common for employees with low-stigma problems to solicit advice from family, friends, and co-workers, they do occasionally receive unsolicited advice. For instance, in the corporate study, several women received unsolicited advice from their supervisors. In these cases, the supervisors became aware of the women's problems because they were crying. Unable to

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tolerate these disruptions on the job, the supervisors compassionately discussed the women's troubles with them and suggested that they seek help from the EAP. In contrast, the alcoholic employees experience more unsolicited comments from co-workers and supervisors than those with less stigmatized problems. For instance, in the corporate program, the two alcohol cases in our sample made no effort to solicit advice about their drinking because they did not regard it as a problem. Consequently, as their drinking progressively disrupted their relationships with family, friends, and co-workers, they began to receive unsolicited advice from them. Finally, their supervisors, unable to tolerate their unsatisfactory performance, confronted them and urged them to seek help from the EAP. Within the union program, alcoholics experience a similar process. Because the union possesses a heavy-drinking culture, early signs of alcoholism were not seen as anything unusual. A A network members, however, did constructively confront co-workers whose drinking they believed was out of control. Some of these drinkers responded by getting their alcohol consumption under control and returning to "normal" drinking. In other instances, the problem drinkers continued to drink heavily, disrupting their relationships at home and work, and the AA members patiently continued to offer them support for quitting and joining the network. Network support appears to function differently for low- and high-stigma problems. For employees with low-stigma problems, it functions as social support, assuring them that their problems are manageable and that they are cared for. For employees with high-stigma problems, however, the network functions as a form of social control giving employees unsolicited advice. Alcoholic employees counter the unsolicited advice with excuses and justifications for their actions and try to escape from future harassment by changing drinking groups. In effect, they abandon their old network of friends for a new one composed of those who are more tolerant of their drinking. For instance, in the union program, alcoholics drifted from one drinking gang to another until they were unable to work at all. Our research suggests that several factors induce employees to recognize that they can no longer control their problems and prompt them to seek help from the EAP. Cultural triggers are learned rationales for seeking professional help: (1) the occurrence of an interpersonal crisis, (2) the perceived interference with social or personal relations, (3) sanctioning, and (4) the perceived interference with vocational or physical activity. Employees learn these rationales from their networks, and they allow employees to reflect upon their own behavior and justify their decisions to seek help. Cultural triggers appear to be related to lowstigma rather than high-stigma problems. In each case, however, employees seek professional advice to evade some kind of social trouble. For instance, employees seek help because they perceive that, if they do not do so now,

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their problems will cause irreparable damage to their personal relationships or jeopardize their employment. For instance, in the corporate program, one woman sought help for her generalized stress, a condition she had had "all of her life," when she was promoted to assistant vice president. Upon self-reflection, she feared that her condition might jeopardize her new job. Employees invoke these rationales then in order to avoid future trouble with members of their networks. Supervisory discussions prompt employees to seek help because of the implicit and explicit threats to their jobs. Employees with both low-stigma and highstigma problems were prompted to use the programs because of unsolicited discussions with their supervisors because, as one employee, who suffered from migraines, succinctly stated it, "He [the supervisor] has a right to expect better [of me]" (Sonnenstuhl, 1982, 285). Such conversations are particularly important in breaking through the denial associated with alcoholism, drug addiction, and severe psychiatric problems. When their supervisors speak, the ultimate consequences of their behavior are revealed, and in order to salvage their work lives they seek help from the EAP. Discussion with co-workers also is a trigger for those with both low- and highstigma problems to seek help. Within each of the sites, there is a loosely organized network of employees who have successfully used the EAP and hold it in high regard. In the case of low-stigma problems, employee conversations with these network members appear to act as a reaffirmation of the employee's decision to seek help and to serve as a source of information about the EAP. For instance, employees in the process of learning to contain their problems will solicit and receive advice from friends, co-workers, and family and will gradually come to realize that they need professional help. Conversations with network members tip the scales toward the EAP, when employees learn they have successfully used the program themselves. In the case of high-stigma problems, employee networks, such as the ones composed of A A members in the union program, are invaluable for breaking through denial. By showing alcoholic employees that a more productive and happier life is possible and by continually extending a supporting hand to them, these networks erode the alcoholics' defenses and induce them to seek help from the program. Before employees with either high- or low-stigma problems actually go to the EAP for help, they must overcome several lingering concerns. Typically, they want to be assured that it will not cost them any money, that they can go during work time, that the therapists will not drug them, and that their confidentiality really will be protected. Assurances from their co-workers and supervisors are important in resolving these lingering concerns. However, if these questions are not resolved, employees will not seek help from the EAP. They will either forego all professional help or will seek it outside of the EAP. Concerns about confidentiality, however, linger long after successful completion of therapy. Specifically, employees worry that their case records will fall into the wrong hands and jeopardize future employment opportunities.

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THE HELPING PROCESS Corporate executives who implement EAPs seem to think of employee assistance workers as performers of "miracle therapy" (Sonnenstuhl, 1986) taking troubled employees off supervisors' hands and putting them into the hands of professionals who will quickly and effortlessly straighten things out (Trice and Beyer, 1984a). Although this illusion may be fostered by such professional symbols as the American Psychiatric Association's Diagnostic and Statistical Manual and numerous outcome studies of clinical interventions (e.g., Smith Glass, and Miller, 1980), experienced therapists, such as the employee assistance workers in our four research sites, assert that counseling remains more of an art than a science (e.g., Frank, 1979; Rachman and Wilson, 1980). For instance, employee assistance counselors in the Family and Children Services agency underscore that they try to help employees resolve their problems but that they cannot fix things for them. They can provide employees with opportunities for insight and skills for working through their problems, but ultimately, the employees must fix things themselves by changing their own behavior and often inducing changes in their social support network of family, friends, and coworkers as well. Trying to help entails first establishing a common language between therapists and employees because counseling is essentially an interpretative process (Horwitz, 1982). Consequently, if therapy is to be successful, its rituals must be meaningful to participants; they must go through it and also believe that going through it will transform them (Hart, 1983). Without such belief, ritual is meaningless and will not work. Psychotherapy uses language to change personality. Unless the therapist and client are able to communicate with one another and unless the client believes in the therapy's efficacy and trusts the therapist, the client will refuse to engage in the therapeutic process, rendering it inoperative (Horwitz, 1982). If the social distance between therapists and clients is too large, psychotherapy generally will not work because therapists and clients who come from different social worlds are unable to communicate with one another (Horwitz, 1982). Employee assistance counselors, who are aware of this phenomenon, are often questioned about whether employees who are not college educated and come from the lower classes could use their services. Consequently, when possible, they refer such individuals to therapists in the community who are skilled in working with lower-class patients. On the other hand, the employee assistance counselors also recognize that minimizing the social distance between themselves and clients increases the likelihood of success. For instance, the union counselors believe that they are successful because, as union members, they understand what it is like to work in the tunnels, which creates immediate rapport with their fellow workers. In a similar fashion, the Family and Children Services counselors attribute the high utilization rates in their program to highly educated employees from the local college who are familiar with mental health services.

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Fitting the rituals of counseling to the clients' social context can minimize the difficulties of social distance (Horwitz, 1982). Employee assistance counselors do this by adopting and integrating both mental health and alcoholism ideologies. Mental health ideology emphasizes clients' individuality in an interchangeable world and the construction of private rituals which are meaningful primarily to clients. The alcoholism ideology emphasizes the commonalities of all alcoholics who live in cultures supportive of their drinking. Consequently, alcoholism counseling is highly ritualized and stresses affiliation with Alcoholics Anonymous' culture of sobriety. According to the mental health ideology, each individual is unique and must learn to adapt to the multiple, often competing, roles of modern life. Consequently, counseling consists of learning to identify the unique self, to nurture it, and to use it in confronting the whole world head on. Modern forms of therapy generally do not entail standardized rituals. Rather, the language, symbols, and rituals, which constitute them, are fitted to the unique self as it experiences the world, becoming "privatized rituals." Generally, mental health specialists believe that the client is their ally in the treatment process and that developing a treatment plan is a cooperative venture in which the client is sufficiently motivated to help identify the problem and to work toward its resolution. For instance, the short-term counseling strategies used by the corporate employee assistance counselors to treat clients' problems were adapted to the needs of the individual employee (Sonnenstuhl, 1986). In treating employees' stressrelated disorders, counselors could choose from a variety of approaches, such as biofeedback and cognitive behavioral therapy, adjusting their technique until they found a meaningful and workable strategy for that particular individual. Similarly, the Family and Children Services and Catholic Charities counselors use a wide range of techniques to assist employees, and like their corporate counterparts, their objective is the same: to increasing their clients' information and their awareness of their own behavior so that they can begin the lifelong work of managing their problems. In contrast, alcoholism treatment focuses upon the communal rather than the individual self, defining the "healthy" person as one who conforms to group standards and suppresses individuality in the services of the group. Consequently, the beliefs and rituals of alcoholism are highly standardized. Alcoholism specialists believe that alcoholism is a disease characterized by denial and that the denial must be overcome to motivate the client to quit drinking and pursue sobriety. In a practical sense, this means that alcoholism specialists are more confrontative with clients than are their mental health counterparts because they must convince clients that their "real" problem is alcoholism and not the stress or family problems claimed by clients. As one social worker with a certificate in alcoholism counseling remarked in our study, "You have to know the difference and manipulate the alcoholics. For them, there is no choice. It is life or death." In addition, alcoholism specialists believe that, in order to achieve sobriety,

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alcoholics must go through a specific rite of passage (Gennep, 1909) in which they are first separated from their alcoholic roles, then put into a marginal or liminal state where they can learn new behavior, and finally incorporated into a new nonalcoholic role. This is essentially what happens when alcoholics are removed from their drinking groups, are put into a treatment or self-help program where they learn sobriety, and are incorporated into Alcoholics Anonymous (Trice and Roman, 1970a). By telling their AA stories, they are able to demonstrate how far they have come by showing that before joining AA their lives were hopelessly disorganized and that after working the Twelve Steps they have become productive members of society (Trice and Roman, 1970a). As such, they are transformed from active alcoholics who deny their alcoholism into members of AA who admit their powerlessness over alcohol and pursue the Twelve Steps to sobriety (Denzin, 1987a, b; Rudy, 1986). They are reincorporated into mainstream America. Although it is possible to find both sets of beliefs in the same practitioner, this is not always the case in the four programs. For instance, the union counselors are well trained in alcoholism but not in assessing other problems; consequently, they compensate by referring nonalcoholic clients to mental health specialists for assessment of their problems. In a similar fashion, many of the mental health specialists in the other three programs are well versed in mental health assessment but are ill prepared to deal with alcoholics. EAPs try to ensure that counselors are knowledgeable about the differences between mental health and alcoholism by having alcoholism advocates on staff and by teaching the counselors the alcoholism ideology. For instance, both the Family and Children Services and the Catholic Charities programs had either credentialed alcoholism counselors or mental health specialists who were also knowledgeable about alcoholism on staff. During staff clinical review sessions, these individuals often drew their colleagues' attention to signs indicating that the case under discussion was really an alcoholism case and helped them to formulate the appropriate alcoholism intervention. In a similar fashion, the directors of both of these programs were skilled clinicians knowledgeable about alcoholism; in their clinical supervision of individual counselors, they would also teach them how to interpret correctly the signs of alcoholism and to formulate the standardized rituals. In contrast, the corporate EAP had no such advocates on staff and consequently identified few alcoholics. When they did identify alcoholics, they frequently had difficulty in breaking through the denial and in motivating them to change. For this reason, the A A in the union program felt that it was possible to sensitize mental health workers to alcoholism as a disease of denial, but that only sober alcoholics could really work with alcoholics. Having been through it, they believe that they can spot the alcoholic and that they really know how to counter their excuses and how to establish trust. Beliefs about alcoholism affect the construction and enactment of these rites of passage in several ways. First, they signal the counselors to inquire about clients' drinking behavior and to regard their responses with a healthy degree

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of skepticism because the employees may be in the throes of denial. In the assessment phase, then, counselors do not expect their clients to ask for help with alcoholism; rather, they are prepared to ask a wide range of questions whose answers may alert them to an underlying alcohol problem. For instance, they inquire about the amount and frequency of the client's drinking; with whom they drink and on what occasions; whether their family, co-workers, or friends have ever been concerned about the client's drinking; and whether the client's family has any history of drinking problems. In addition, counselors may draw upon their own knowledge about the employee's workplace in order to ascertain whether there is a drinking culture within the organization, the employee's involvement in it, and whether the employee has experienced any problems at work because of intoxication or hangover. Although such inquiries would appear to be self-evidently part of any therapist's assessment, our observations suggest that they are not and that, unless the counselors are attuned to the alcoholism ideology, they are likely to accept the alcoholics' excuses and accounts at face value. For instance, on several occasions, counselors reported on difficult cases in the clinical review sessions only to learn from their colleagues that they had too quickly accepted the clients' accounts and that a little deeper probing and reinterpretation of the known facts indicated that the clients were alcoholics. Once alerted to a potential alcohol problem, the counselors look for ways to build their case with the objective of helping the alcoholic realize that his or her drinking is not normal and initiating a rite of separation—that is, to remove the client from the supportive drinking network by getting him or her into AA or an alcoholism treatment unit. In doing so, the counselors seek a "hook" to motivate the client to change. Frequently, they seek more information on the client's drinking behavior by including a spouse or other family members in the assessment process. Job performance difficulties are always greeted as valuable information for breaking through the denial. In negotiating with their alcoholic clients, counselors employ a variety of techniques. In some instances, they are didactic, using the Jellinek curve and employees' genograms to show them symbolically that they have serious drinking problems and that they need treatment. Always the long-term effects of job loss and death are recounted and backed up with concrete examples of trouble from the client's life. In some instances, reluctant clients are assigned to attend AA meetings in the hope that they will be able to identify with those telling their stories; in others, clients are encouraged to accept detoxification by assuring them that their cases require more detailed assessment before a definite diagnosis can be made. In negotiating with alcoholic clients, employee assistance counselors depict themselves as manipulating the clients into treatment. This depiction is anathema to their mental health colleagues who often see manipulation as unethical because it conflicts with what the client wants. However, the employee assistance counselors believe that it is necessary and without such confrontation their alcoholic clients are doomed. Consequently, they speak of "first things first"; treat the

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alcoholism first and later the attendant work and family problems will resolve themselves. For the employee assistance counselors, then, their active involvement with alcoholic clients often ends once they are able to help them see that their drinking is not normal and that they have to separate themselves from their group supports. Consequently, the liminal and reincorporation stages of the rite of passage to sobriety occur elsewhere, outside of the counselors' sight and without their involvement. As such, they play an important linking role in the therapeutic process, but they are not the primary actors. The standardized rituals of alcoholism treatment are enacted elsewhere. In contrast, the rituals of mental health problems are not standardized, and the concerns of employees generally are taken at face value. Employees who present themselves to the program feeling anxious and overstressed because of family and work problems will generally be accepted as such. Counselors will generally seek to help them relieve the anxiety and stress by helping them to find immediate solutions to their family or work difficulty and by then teaching them generalized techniques for managing their troubles. In addition, problems are approached piecemeal. That is, unlike the alcoholism treatment process, which requires a basic transformation of self and social supports, the treatment process of most other problems is incremental. Consequently, the learning objectives negotiated between counselors and clients do not encompass either a new role or a total change of network support. Rather, they include learning incrementally how to be a better person, parent, or spouse, and the counseling process consists of providing clients with the tools to begin a lifelong process of self-discovery and self-fulfillment. These remarks are not intended to convey the idea that working with employees' troubles is easy or frivolous. Indeed, it is very difficult work precisely because there are so few standardized rituals for helping clients. Consequently, the counseling process is fraught with attempts to find a meaningful frame for managing employees' concerns. Indeed, there may be as many routes to selffulfillment and familial happiness as one is free to imagine, but not all are really meaningful to participants. The difficulty of constructing meaningful rituals was dramatically highlighted by a very experienced counselor who spoke about the "textbook case" with whom she was working. She kept going on about how she had done exactly what the books say one should do and the real surprise was that it worked. She was so accustomed to working at constructing meaningful ritual that when it happened according to a textbook example, she was taken aback. Indeed, because it was so easy, she kept looking for assurance that it had really worked. TIME CONSTRAINTS Time as well as ideology constrains the ritual of employee assistance counseling. Of the four EAPs, only the union program had no constraints upon how

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much time counselors could work with employees. The Family and Children Services generally could see employees up to eight sessions before having to refer them other community agencies or therapists for longer term help. However, in some instances, they would see clients longer if they were unable to refer the clients elsewhere and if they believed that the clients needed more help to bridge them over to such a referral. In the corporate and Catholic Charities programs, the original policies of unlimited sessions were eventually cut back to a small number of assessment sessions (e.g., three or four) after which the employees were to be referred to community agencies and therapists. These constraints were required because, as the number of employees coming to the EAPs increased, the program directors found that the only way they could provide services to everyone and remain solvent was to cut back on services by foregoing attempts at short-term counseling and concentrating upon assessment and referral. In a practical sense, time constraints were not problematic for alcoholism cases because they are so standardized. However, they became problematic for other cases, for a variety of reasons. First, if the counselors felt that the trouble could be resolved in a brief time, they generally preferred to stay with a case rather than refer it on. This allowed them to use more of their skills than they would otherwise use if they provided only assessment and referral. Consequently, counselors often resisted the imposition of time constraints, and, in several instances, counselors felt as though they were being forced to abandon their clients. Some even break the rules by seeing clients for extended periods of time. These feelings are compounded by employee demands that counselors see them longer rather than refer them elsewhere and by the reality that there often is nowhere else to go. For instance, both the corporate and Catholic Charities programs were unable to refer employees quickly on to other services because these, too, were full. This put increasing pressure upon the counselors to fulfill their ethical duties by providing counseling services. Time constraints, then, make it difficult for employee assistance counselors to work through entire cases with employees. Consequently, the employee assistance counselors kept struggling to clarify their goals in working with clients. How much of the therapeutic work can they do and who can they rely on to carry through with clients? These are not easy questions to answer, especially when counselors have been trained to do the job themselves and when therapeutic goals are so evolutionary. Short term, they divided the process into ever more discrete learning objectives; long term, however, the ultimate goal remained insight into the self so that individuals can construct for themselves a fulfilling life. LOCATION OF THE EAP The program's location vis-a-vis the workplace also plays an important role in the therapeutic process. Although both the union and corporate programs are described as being inside their respective work organizations, they have radically

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different relationships to them. Because it is built around a network of union members who are A As, the union program is intimately involved in day-to-day activities. The corporate program, however, remains isolated in the medical department because its policy stated that counselors could be involved with employees only when the employees initiated contact. This policy extended to contacting employees who missed their appointment. The program feared that contacting them would appear to the employees to be harassment. The two outof-house programs also had little or no contact with the contracted work organizations, except when employees made contact with them. A practical consequence of this isolation was that all three of the programs lost touch with the employees after they left the program, further underscoring the individual nature of mental health treatment. Indeed, in all three of the programs, counselors said that one of the most frustrating things about their work was not knowing what happened to employees after they left. In sharp contrast, the union program was well aware of what happened to union members because the counselors and AAs took an active role in the rite of reincorporation. When an individual returned from alcoholism treatment, the members got him a job on a gang where at least one of the members was an AA, moved his locker into the A A section, and took him to A A meetings after work. These acts dramatically highlighted that he remained a member of the union but occupied a new status as a sober member. In addition, these activities reinforced what the individual had learned in alcoholism treatment—he was an alcoholic and to remain sober he would need the support of AA. CONCLUSIONS Our preliminary analyses have partially illuminated the dual strategy by widening our research lens and looking at the help-seeking and helping processes involved in EAPs. These analyses reveal that employees' alcohol and other emotional troubles exist within different social contexts and that the therapeutic approaches constructed by EAP workers reflect these contexts. Alcohol problems exist in a communal context. Alcoholic employees receive social support for their behavior from drinking groups and will not seek help until some outside force intrudes, forcing them to recognize that their drinking is a problem. Once they accept help, therapy reflects the communal context of alcohol problems and consists of a highly standardized rite of passage whereby individuals are transformed from drinkers into sober members of AA. Other emotional troubles, however, exist in an individual context, and employees experience them as uniquely their own. Employees who are knowledgeable about the mental health ideology become aware of potential problems in themselves, and they use their social support networks to confirm their beliefs that they need help. In contrast, employees who are not knowledgeable about the mental health ideology become aware of it when their behavior disrupts their ongoing interpersonal relationships and their networks tell them that they need help. In these cases, therapy is not

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highly ritualized, and counselors and clients together must seek a meaningful ritual that will explain the distress. These insights may partially illuminate some of H.M. Trice and J. Beyer's earlier findings. For instance, they found that confrontative topics (e.g., poor work performance and possible disciplinary actions) were predictive of alcoholic employees accepting help and that constructive topics (e.g., personal problems and availability of counseling) were predictive of other troubled employees accepting help. These differences probably reflect the different ways in which alcoholic and troubled employees experience help seeking. Alcoholic employees caught up in the web of social supports for their drinking experience supervisors' confrontative comments as a form of social control, breaking down their denial and forcing them to see that things really are out of control and that they need help. Employees with other troubles, who believe in the mental health ideology, however, experience supervisors' constructive comments as support for their suspicions that they really do need professional help. At the same time, the insights also suggest that one reason that many employees with other troubles do not accept help is that they do not believe in the mental health ideology; consequently, discussions of their personal problems and offers of professional help are of little avail to them. Additionally, these insights suggest why the dual strategy may be more effective with alcoholic than other troubled employees. Simply stated, alcoholism treatment's standardized rite of passage is an easier and simpler therapeutic process to implement than the unstandardized rituals for other troubles. Once employees have been motivated to comply with treatment via constructive confrontation, everyone knows exactly what must be done. Alcoholics must quit drinking, learn to live a sober life, and join AA. The process is unequivocal and produces a new social network that provides ongoing support for living a sober life. In stark contrast, other mental health rituals have no clearly defined rite of passage leading to a new social role and new social supports. At the same time, our findings raise many new research questions. For instance, we still know very little about the help-seeking behavior of employees, and new research must look at how the help-seeking process varies according to the employee's social network, social class, age, sex, and type of problem. In particular, data are needed that compare users and nonusers of EAP in order to understand what prompts some to use EAP services and others to seek help elsewhere or to solve their problem themselves. Second, the use of the alcoholism ideology raises questions about how EAPs identify and work with problem drinkers. Some observers (e.g., Fillmore and Kelso, 1987) fear that, due to the upsurge in the ideology's popularity, many problem drinkers may be coerced into unnecessary treatment. This is of practical significance in the maintenance of long-term sobriety because repeated studies have shown that successful affiliation with Alcoholics Anonymous depends upon the affiliates' having experienced intense social reaction to their drinking by others (Trice, 1957; Trice and Roman, 1970b). Clients who do not experience

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these reactions are also less likely to do well in alcoholism treatment (Moberg, 1976). Third, the movement toward EAPs as a form of managed health care is predicated on the belief in standardization; however, such standardization is lacking in most areas of mental health because of the ideology's emphasis upon the uniqueness of the individual. Short-term counseling techniques, such as biofeedback and cognitive therapy, have been one response to tightening up on time constraints; however, we have no data on their effectiveness within EAPs. Consequently, research on these techniques is urgently needed. Finally, follow-up studies are needed in order to discover what really happens to employees who have sought help and received it from the EAP. If, as our preliminary analyses suggest, treatment and recovery are related to social context, one would expect to see alcoholics affiliating with Alcoholics Anonymous and other troubled employees managing problems on their own. If so, what do they do in order to ensure that the changes which began in the treatment setting are carried over into work and family life? NOTES I gratefully acknowledge the Christopher D. Smithers Foundation, Mill Neck, New York, for support during the preparation of this manuscript. 1. For a more detailed example of the constant comparative method, see Sonnenstuhl (1986), in which the method used to generate a theory to explain EAP self-referral is described.

REFERENCES Bissell, L., and Haberman, P.W. (1984). Alcoholism in the professions. New York: Oxford University Press. Charmaz, K. (1983). The grounded theory method: An explanation and interpretation. In R. Emerson (Ed.), Contemporary field research. Boston: Little, Brown and Company. Cockerham, W.C. (1981). Sociology of mental disorder. Englewood Cliffs, NJ: PrenticeHall. Denzin, N.K. (1987a). The alcoholic self Newbury Park, CA: Sage Publishing. Denzin, N.K. (1987b). The recovering alcoholic. Newbury Park, CA: Sage Publishing. Emerson, J.P. (1970). Nothing unusual is happening. In T. Shibutani (Ed.), Human nature and collective behavior. Englewood Cliffs, NJ: Prentice-Hall. Fillmore, K.M., and Kelso, D. (1987). Coercion into alcoholism treatment: Meanings for the disease concept of alcoholism. The Journal of Drug Issues, 17 (3), 301— 319. Frank, J. (1979). The present status of outcome studies. Journal of Clinical Psychology, 47, 310-316. Gennep, A.Y. (1909). Les Rites de Passage. Paris: Libraire Critique, Emil Mourry. Glaser, B. (1978). Theoretical sensitivity. Mill Valley, CA: The Sociology Press.

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Glaser, B., and Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine Publishing. Hart, Onno Van der. (1983). Rituals in psychotherapy: Transition and continuity. New York: Irvington Publishers. Hawkins, R., and Tiedeman, G. (1975). The creation of deviance: Interpersonal and organizational determinants. Columbus, OH: Bell and Howell Company. Horwitz, A. V. (1977). The pathway into psychiatric treatment: Some differences between men and women. Journal of Health and Social Behavior, 18, 169-178. Horwitz, A.V. (1982). The social control of mental illness. New York: Academic Press. Jackson, J. (1954). The adjustment of the family to the crisis of alcoholism. Quarterly Journal of Studies on Alcohol, 15, 564-586. Kadushin, C. (1969). Why people go to psychiatrists. New York: Atherton Press. Lemert, E.M. (1951). Social pathology. New York: McGraw-Hill. Lester, M., and Hadden, D.C. (1980). Ethnomethodology and grounded theory methodology. Urban Life, 9(1), 3-33. Moberg, P. (1976). Treatment outcomes for earlier-phase alcoholics. Annals of the New York Academy of Sciences, 273, 543-552. Rachman, S.J., and Wilson, G.T. (1980). The effects of psychological therapy (2nd ed.). New York: Pergamon Press. Roman, P.M. (1988). Growth and transformation in workplace alcoholism programming. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 131-158). New York: Plenun Press. Rudy, D.R. (1986). Becoming alcoholic. Carbondale: Southern Illinois University Press. Smith, M.L., Glass, G.V., and Miller, T.I. (1980). The benefits of psychotherapy. Baltimore, MD: The Johns Hopkins University Press. Sonnenstuhl, W.J. (1982). Understanding EAP self-referral: Toward a social network approach. Contemporary Drug Problems, 11, 269-293. Sonnenstuhl, W.J. (1986). Inside an emotional health program: A field of study of workplace assistance for troubled employees. Ithaca, NY: ILR Press. Sonnenstuhl, W.J., Staudenmeier, W.J., and Trice, H.M. (1988). Ideology and referral categories in employee assistance research. Journal ofApplied Behavioral Science, 24, 383-396. Sonnenstuhl, W.J., and Trice, H.M. (1986). Strategies for employee assistance programs: The crucial balance (Key Issues Series No. 30). Ithaca, NY: ILR Press. Sonnenstuhl, W.J., and Trice, H.M. (1987). Social construction of alcohol problems in a union's peer counseling program. Journal of Drug Issues, 17 (3), 223-254. Sonnenstuhl, W.J., Trice, H.M., Staudenmeier, W.J., and Steele, P. (1987). Employee assistance programs and drug testing: Fairness and injustice in the workplace. Nova Law Review, 11, 709-731. Strauss, A. (1987). Qualitative analysis for social scientists. Cambridge, England: Cambridge University Press. Trice, H.M. (1957). A study of the process of affiliation with Alcoholics Anonymous. Quarterly Journal of Studies on Alcohol, 18, 39-54. Trice, H.M. (1966). Alcoholism in America. New York: McGraw-Hill. Trice, H.M. (1984). Alcoholism in America revisited. Journal of Drug Issues, 14 (1) Winter, 109-123. Trice, H.M., and Beyer, J. (1984a). Employee assistance programs: Blending performance-oriented and humanitarian ideologies to assist emotionally disturbed em-

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ployees. In J.R. Greenley (Ed.), Research in community and mental health (Vol. 4). Greenwich, CT: JAI Press. Trice, H.M., and Beyer, J. (1984b). Work related outcomes of constructive confrontation strategies in a job-based alcoholism program. Journal of Studies on Alcoholism, 45, 393-404. Trice, H.M., and Roman, P.M. (1970a). Delabeling, relabeling and Alcoholics Anonymous. Social Problems, 17, 468-480. Trice, H.M., and Roman, P.M. (1970b). Sociopsychological predictors of affiliation with Alcoholics Anonymous. Social Psychiatry, 5, 51-59. Trice, H.M., and Roman, P.M. (1978). Spirits and demons at work: Alcohol and other drugs on the job (2nd ed.). Ithaca, NY: Publications Division of the New York State School of Industrial and Labor Relations at Cornell University. Trice, H.M., and Sonnenstuhl, W.J. (1988). Constructive confrontation and other referral processes. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 159-170). New York: Plenum Press. Veroff, J., Kulka, R., and Douvan, E. (1981). Mental health in America: Patterns of help-seeking from 1957-1976. New York: Basic Books. Yarrow, M. et al. (1955). The psychological meaning of mental illness in the family. Journal of Social Issues, 11, 12-24.

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17 WORKPLACE INFLUENCES ON ATTITUDES ABOUT ALCOHOLISM JANET S. MOORE

Since the 1940s the workplace has been targeted as a setting for alcohol problem intervention (Trice and Schonbrunn, 1981). Over the past decade the workplace has gained special prominence as a site for the identification and rehabilitation of problem drinkers (Roman, 1988). The rationale for this choice is complex and multifaceted, but it is enmeshed, at least partially, in the thrust by the National Council on Alcoholism (NCA) and later by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to change the public's image of the alcoholic and ultimately to promote a humanitarian and medicalized approach to the problems of alcohol abuse and alcoholism (Roman, 1981). Despite the importance of the role afforded to workplace intervention programs in changing public beliefs and opinions about alcoholism, there is essentially no empirical literature that directly addresses the impact that these programs have had. There is, however, research which bears indirectly on the subject. This chapter includes a review of the historical role of the workplace in altering attitudes about alcoholism and the alcoholic. Second, the existing literature as well as some new data relevant to the influence of workplace alcohol programs on attitudes about alcoholism are presented. Finally, the implications of findings for prevention and intervention efforts in the workplace are discussed.

THE HISTORICAL ROLE OF THE WORKPLACE IN PROMOTING ATTITUDES ABOUT ALCOHOLISM NCA, with the support of Alcoholics Anonymous (AA) and the Yale Center for Alcohol Studies, had as its early mission the promotion of a compassionate and humane approach to the treatment of alcoholics (Roman, 1988). In order

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for this approach to be adopted by the general public, the image of the alcoholic had to be altered from that of a moral degenerate who had sunk to the lowest depths of society to that of a middle-class citizen who was very much a part of mainstream life (i.e., someone with whom the general populace could identify and, consequently, feel compassion for). According to the publicity campaigns of NCA, the skid-row bum represented only 5 percent of the alcoholics in society. The other 95 percent were said to be "hidden" in the fabric of everyday life. Although there is some question as to the accuracy of this depiction, few would argue that the new image of the alcoholic was less likely to evoke social disgust, rejection, and punishment and more likely to elicit empathy, acceptance, and charity than was the old image. Conceptualizing alcoholism as a disease reinforced the new portrayal of the alcoholic. If alcoholism is a "disease like any other" then all persons regardless of social class are equally at risk for developing the condition. Additionally, if alcoholics have a disease, then they cannot be held responsible for the development of their condition. Persons who have physical diseases are usually considered victims who have no control over the onset of the disease (Friedson, 1966; Weiner, Perry, and Majussion, 1988). Therefore, according to the medical model, alcoholics are not morally defective persons on the fringes of society who have not exercised the self-control needed to resist the seduction of alcohol, but are instead persons from the mainstream of society whose biological makeup prevents them from tempering their alcohol consumption. A primary facet of the promotion of the middle-class, "sanitized" image of the alcoholic was the placement of this individual within the workplace, thereby promoting the assertion that 95 percent of the alcoholics were not on skid row but were engaged in the activities of respected citizens, namely work (Trice and Schonbrunn, 1981). To reinforce this claim, programs for dealing with alcohol problems became centered in the workplace. After all, if the workplace is where most alcoholics are found, then it follows that programs for the identification and assistance of problem drinkers would be located within this setting. Thus, one way in which workplace intervention programs were involved in changing attitudes about alcoholism and alcoholics was by acting as testimony to the claim that most alcoholics are hardworking citizens who are worthy of the compassion and charity of others. In fact, the continued existence and growth of workplace programs could be construed as evidence for the contentions of NCA and NIAAA that many alcoholics are working-, middle-, and upper-class members of society. The workplace was expected to encourage a positive, accepting attitude toward alcoholics through another mechanism as well. Through the presence of employee alcoholism programs, an atmosphere of concern and tolerance toward the issue of problem drinking was to be established in the work setting (Roman and Blum, 1985). The message to be sent to employees was that management was accepting of alcohol problems; employees were not viewed negatively as a result of problem drinking, and management would not engage in punitive actions toward them

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without first offering support and assistance. This humane philosophy was to be conveyed to employees through supervisors, and eventually, employees were expected to convey this message to the outside world. To some extent, broadbrush employee assistance programs (EAPs) now have been assigned the role of promoting a humanitarian philosophy toward alcoholism and the alcoholic in the workplace. P.M. Roman and T.C. Blum (1985) have identified a core of activities that are performed through EAPs. This group of activities, or core technology, comprises six elements, one of which is relevant to the issue of the role of the workplace in promoting attitudes about alcoholism. According to the authors, one activity of employee assistance programs is the promotion of the idea that the workplace is the setting where alcohol problems can be dealt with effectively as well as constructively. Through the efforts of EAPs, management conveys a position of tolerance and an acceptance of alcohol problems which supposedly is diffused into the population of rank and file employees, who then carry the attitude into the larger society. Finally, the workplace was expected to alter attitudes about alcoholism by affording the opportunity for persons to see problem drinking co-workers receive assistance for their drinking behavior, recover from the problem, and return to work (Roman and Blum, 1985). Viewing this process was anticipated to promote beliefs about aspects of alcoholism that NCA, NIAAA, and A A had hoped to instill in the public, namely that alcoholics are not lost souls but are persons with physical diseases who, with appropriate treatment, can return to "normal," productive lives. Alcohol educators hoped that by viewing the recovery process firsthand, employed persons would become convinced that alcoholism was treatable and, consequently, would be more socially conscious and feel more charitable toward the issue of alcoholism. WORKPLACE ATTITUDES ABOUT ALCOHOLISM AND ALCOHOLICS There have been no studies that have had as a primary focus the impact of workplace alcohol programs on beliefs about alcoholism and attitudes toward alcoholics. For example, there are no data that directly speak to the influence that workplace intervention programs have had on the public's stereotype of the alcoholic (i.e., the replacement of the skid-row bum with the working-man image of the alcoholic). Additionally, there are only very sparse data on the influence of seeing a co-worker recover from problem drinking on attitudes about alcoholism. There are data, however, that indirectly address the influence workplace alcohol programs have had on promoting tolerant and compassionate attitudes toward the issue of alcoholism (i.e., the promotion of the disease concept, the eradication of the moral concept, and the promotion of social and work acceptance of the alcoholic). Two studies are reviewed that compare the attitudes toward alcoholism and the alcoholic of employees in work settings that have employee alcohol programs

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to the attitudes of employees in settings where no such programs exist. If workplace alcohol programs are having the expected impact, then employees in settings that have alcohol programs should have more compassionate attitudes toward alcoholism and alcoholics than should other employees. Then a study that looks at attitudes of supervisory persons toward problem drinking is reported. It is quite likely that in many workplaces supervisors rather than personnel in employee assistance programs are responsible for conveying management's attitudes about alcoholism to the rank and file employee. Their beliefs about alcoholism and their reactions to the problem-drinking employee then become the model for rank and file employees' attitudes about alcoholism. Attitudes about alcoholism will be explored across three domains: (1) acceptance of the disease concept of alcoholism, (2) rejection of the moral stigma attached to alcoholism, and (3) social and workplace acceptance of the alcoholic. Finally, the interrelatedness of the three domains will be investigated to assess the relationship between beliefs about the nature of alcoholism and the reactions to the alcoholic. Alcohol educators had hoped that acceptance of the disease concept would bring about a rejection of the moral concept which, in turn, would promote acceptance and charity toward the alcoholic. In order to explore this proposition, social and work acceptance will be looked at as a function of beliefs in the medical and moral concepts of alcoholism. Acceptance of the Disease Concept There is a good deal of evidence that the medical model of alcoholism has met with increasing acceptance since the 1940s and is now widely accepted by a large percentage of the general population in the United States. As early as 1949, J.W. Riley (1949) was able to demonstrate that 20 percent of his sample agreed with the statement that the alcoholic is a sick person. H.A. Mulford and D.E. Miller, working with an Iowa sample in the 1960s, obtained a 50 percent agreement in one study with the statement that the alcoholic is sick (Mulford and Miller, 1961) and a 65 percent agreement in another study (Mulford and Miller, 1964). In more recent studies, M.B. Rodin (1981) reported that 71.6 percent of a sample from Chicago endorsed the statement that alcoholism is a physical disease: 91 percent of the respondents in a Contra Costa County, California, study (Caetano, 1987) and 89 percent of a Georgia sample (Blum, Roman, and Bennett, 1989) agreed that the alcoholic is ill. Although a plethora of opinion surveys has been conducted with the general public, there is little data dealing with beliefs about alcoholism as a disease among persons in the workplace who are not alcohol professionals. Certainly among alcohol professionals in the workplace there is overwhelming acceptance of the disease concept (Bennett and Kelley, 1987), but little is known about the beliefs of nonprofessionals. Additionally, there has been no attempt to study the influence that workplace alcohol programs have had on acceptance of the disease concept. A study of a representative sample of adults in the state of Georgia,

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however, has yielded data relevant to this concern. A random sample of 524 adults were interviewed by telephone as part of a large survey research effort conducted by the Institute for Behavioral Research at the University of Georgia (Blum, Roman, and Bennett, 1989). Of the 524 adult respondents in the study, 370 were in the work force. Approximately 25 percent of these persons were employed in situations where an employee assistance program existed, and 75 percent were employed in situations where no such program existed. Using a "yes-no" response format, respondents were asked "Do you think the term sick person applies to the alcoholic?" and "Do you think the alcoholic should be viewed and treated as someone who is ill?" Approximately 75 percent of all employed persons, regardless of the presence or absence of an employee alcoholism program, responded affirmatively to the first question, and approximately 87 percent gave an affirmative response to the second. When the responses of persons employed in settings with employee alcohol programs were compared to persons employed where no such program existed, however, there were essentially no differences between the two groups in their endorsement of the medical model. A study conducted in 1974-1975 with 1,647 supervisors in a sample of federal agencies in the Atlanta and Dallas civil service regions offers additional information about the diffusion of the disease concept into the workplace (for further details about this research and other findings from it, see Hoffman and Roman, 1984a, b). The study was conducted four years after Public Law 91-616 mandated that federal agencies implement workplace programs for dealing with alcohol problems. Approximately 15 percent of the supervisors in the study had received some training on the guidelines of the Federal Employee Alcohol Policy. Included in the study was an item dealing with beliefs about the nature of alcoholism. Supervisors were asked to classify problem drinking into one of the following categories: a physical disease, a mental health problem, a behavior problem, a lack of self-control, or a health problem that is the result of a lack of self-control. Two items could be construed as dealing with the medical nature of alcoholism (problem drinking as a physical disease and problem drinking as a health problem resulting from a lack of self-control). Approximately 22 percent of the sample agreed that alcoholism is best classified as a physical disease; 24 percent of the sample indicated that alcoholism is best classified as a health problem resulting from a lack of self-control. Altogether approximately 46 percent of the sample, given a forced-choice format, classified alcoholism as clearly having a medical component. Although both of these categories deal with the medical nature of alcoholism, only the first category, alcoholism as a physical disease, is the basis of the disease concept as advocated by NCA and others. However, items used in previous studies such as "the alcoholic is sick," "alcoholism is an illness," and "the alcoholic should be viewed and treated as someone who is ill" may be tapping both beliefs about the etiology of alcoholism (i.e., a disease) and about the consequences of alcoholism (i.e., health problems). The separation of these two

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beliefs in the present study may be responsible, in part, for the lower level of endorsement of the physical disease concept than has been reported in other studies conducted in the 1970s. Additionally, it should be noted that approximately 43 percent of the respondents endorsed the ambiguous categories of alcoholism as a mental health or behavior problem. At any rate, it is unlikely that workplace supervisors in federal agencies are less accepting of the disease concept of alcoholism than is the general public. If offered the format of questions used in other studies, these supervisors probably would have shown a similar pattern of response. Instead, the discrepancy is probably an artifact of differences in instrumentation. These findings are informative, however, since other methods reveal whether persons believe alcoholism is an illness or not. Here, it is clear that there is a mixed set of beliefs. This mixture may indeed affect the use of workplace intervention programs. A portion (15 percent) of the supervisors in the study had received some training on the Federal Employee Alcoholism Policy. Although this report of training represented a variety of experiences, one would expect that it was oriented toward the physical disease model, consistent with the Federal Employee Alcoholism Policy. Interestingly, however, there were essentially no differences among supervisors who had received training on the new policy and those who had not in their endorsement of the disease concept of alcoholism. These findings appear to indicate that the educational training given to supervisors may have informed them of the alcohol policy and how it was to be implemented, but did not impact beliefs about alcoholism or reactions to the alcoholic. The Georgia survey data and the data from the federal supervisors raise the question about the effectiveness of educational efforts in the workplace. In the Georgia poll, the presence of an employee alcoholism program had no effect on employees' attitudes. In the study of federal supervisors, there was only minimal support for the disease concept, and thus, it is quite unlikely that this particular attitude was being modeled for employees. Additionally, those who had received training on the Federal Employee Alcoholism Program did not differ from those who had not in their endorsement of the medical model of alcoholism. Certainly, the disease concept enjoys wide acceptance among the general public, but there is little evidence that educational efforts at the level of the workplace are responsible for this phenomenon. Rejection of the Moral Stigma Associated with Alcoholism Early alcohol educators had hoped that with the acceptance of the medical model of alcoholism would come a rejection of the moral stigma attached to the condition. This expectation is supported by a rich empirical literature demonstrating that conditions for which individuals are not held morally responsible evoke fewer negative attributions to the victims than do conditions for which the victims are held responsible (Farina, Holland, and Ring, 1966; Freeman, 1961). The early image of the alcoholic and the image that NCA wanted to

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change was that of a moral degenerate who lacked the willpower to control his or her behavior; the alcoholic was viewed as being responsible both for bringing on the alcoholic condition and for its alleviation. Studies beginning in the 1940s and continuing to the present have shown a steadily decreasing tendency for the public sector to view alcoholism as strictly a condition of moral weakness or weak will (Orcutt, Cairl, and Miller, 1980). Respondents continue, however, to view alcoholism as having a moral component (i.e., when they are not faced with a forced-choice format and can rate alcoholism as both a medical and a moral condition, a large percentage of the population continues to rate the alcoholic as morally weak). In 1964, Mulford and Miller found that 31 percent of their Iowa sample agreed that alcoholics were morally weak, and 60 percent agreed that they were weak-willed. Fortyone percent of their sample characterized the alcoholic as both sick and morally weak. J.D. Orcutt, R.E. Cairl, and E.T. Miller (1980) found that 59 percent of their sample subscribed to both the moral and sickness beliefs about alcoholism, 5 percent to the moralistic only, 34 percent to the medical only, and 2 percent to the behavioral (i.e., neither medical nor moralistic). In a very recent study, T.C. Blum, P.M. Roman, and N. Bennett (1989) report data indicating that 47 percent of their sample characterized the alcoholic as morally weak, and 35 percent characterized the alcoholic as both morally weak and sick. Attributions of responsibility to the alcoholic are also evidence of a moral overtone to beliefs about the nature of alcoholism. A number of studies indicate that a large percentage of the population believes that alcoholics should be held responsible for their condition even if they also endorse the physical disease concept of alcoholism (Blum, Roman, and Bennett, 1989; Caetano, 1987; Orcutt, Cairl, and Miller, 1980). Clearly, the moral stigma attached to alcoholism has not been displaced by the disease model as alcohol educators had expected. Instead, many people appear to have embraced the disease concept of alcoholism while steadfastly holding to the belief that alcoholics are morally inferior and should be held responsible for their condition. This response pattern has been characterized by a number of researchers as evidence of the public's ambivalence about alcoholism, and it has led many to marvel at the capacity of persons to hold incongruous beliefs (Room, 1983). As discussed earlier, however, several methodological issues need to be resolved before this particular response pattern can be taken as evidence of psychological ambivalence. Although the data clearly indicate that there continues to be a moral stigma attached to problem drinking among the general public, attitude change efforts may have been more effective in the workplace. Again there is a paucity of data that deals with the influence of workplace factors on beliefs about the nature of alcoholism. The two studies reported earlier (i.e., the study of a sample of persons in the work force in Georgia and the study of supervisors in federal installations), however, are relevant to the current discussion. In the study of Georgia residents in the work force, 42 percent of the sample

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agreed that the term morally weak applied to the alcoholic. Thirty-five percent agreed that both the disease concept and the moral concept applied to alcoholism. Again, persons employed in settings that had alcohol intervention (employee assistance) programs did not differ in the extent of their agreement with the moral concept nor in their tendency to classify alcoholism as both a moral and medical condition from persons who did not work in settings with alcohol intervention programs. In the study of federal supervisors in the Atlanta and Dallas areas, a moral overtone is evident in the beliefs expressed about alcoholism. Approximately 9 percent of the respondents indicated that problem drinking could best be classified as a lack of self-control, and another 24 percent of the respondents classified problem drinking as a health problem that results from a lack of self-control. Thus, approximately 33 percent of the respondents, when presented with a forcedchoice format, classified problem drinking as a problem of self-control. When given the opportunity to respond to items measuring beliefs about alcoholism as a disease and as a condition of weak moral character, 10 percent of the federal supervisors indicated agreement with both statements. Again, the pattern of response was unchanged through participation in training sessions on the Federal Employee Alcoholism Policy.

Social and Work Acceptance of the Alcoholic Research on samples of the general public shows that the alcoholic continues to be stigmatized and to experience social rejection despite the public's endorsement of the disease concept. The label of alcoholic or problem drinker evokes unfavorable connotations (Cash et al., 1984; Kilty, 1981; Kilty and Meenaghan, 1977; Stafford and Petway, 1977), and certainly behavioral descriptions of excessive drinking bouts elicit intolerance and social rejection (Cash et al., 1984; McNeil and Janzen, 1987). Common perceptions of alcoholics include unpredictability (Orcutt, Cairl, and Miller, 1980), not being in control (Cash et al., 1984), and being threatening (Orcutt and Cairl, 1979; Reis, 1977). Alcoholics tend to be rejected as friends (Cash et al., 1984; Kilty and Meenaghan, 1977), as marriage partners, and as roommates (Blizard, 1970). Generally, people feel uncomfortable around alcoholics (Orcutt, Cairl, and Miller, 1980), and alcoholics enjoy less respect from peers than do nonalcoholics (Kilty and Meenaghan, 1977; Stafford and Petway, 1977). The alcoholic not only meets with rejection in social situations, but also encounters a lack of acceptance in the workplace. As discussed earlier, alcohol educators had hoped to set a tone of tolerance and compassion toward alcoholism in society as a whole, but particularly in the workplace. Although the evidence is quite sparse, both the alcoholic and the recovering alcoholic, who generally is regarded more positively than the alcoholic (Kilty, 1981), are not unequivocally accepted in the workplace (Blizard, 1970; Cash et al., 1984). In fact, K.M.

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Kilty (1975) found that having an alcoholic employee is viewed more negatively than having an alcoholic in another aspect of one's life. Persons in the workplace who have received some education about alcohol problems and possibly have had the opportunity to see co-workers plagued by alcohol problems receive some type of assistance, however, would be expected to evidence greater compassion toward alcoholics than would the general public. Data from two sources address this issue. First, an unpublished study of Georgia residents conducted in 1987 yielded information concerning the role of workplace programming in promoting a tolerant approach to the alcoholic. A sample of 527 individuals, chosen to be representative of the total population of the state of Georgia, were interviewed by telephone. Of the 527 respondents, 349 were employed at least on a part-time basis; 118 of them were employed in settings with alcohol intervention programs, and 231 of them were employed in situations where no such program existed. Respondents in the study were read a brief scenario that described a neighbor who had had a drinking problem for ten years and, consequently, had had many family and job problems. Two versions of the scenario were presented: in one, the individual was described as having spent a month in an inpatient treatment center, in another, the individual was described as having begun to attend Alcoholics Anonymous two years earlier. In both cases, the individual had not had a drink for two years. Respondents then answered several questions concerning their reactions to the individual in the scenario, two of which were related to acceptance in the workplace. The independent variables of interest in this study were the presence or absence of an employee assistance program in the workplace and the method of treatment—Alcoholics Anonymous or inpatient treatment. The independent variable, method of treatment, is pertinent to the understanding of the depth of the diffusion of the disease concept in the workplace. Inpatient treatment is part of the medicalized conception of alcoholism—one must be placed in a hospital setting with medical personnel in order to regain one's health. The variable was included to determine if this particular aspect of the medical model of alcoholism has been adopted. Approximately 80 percent of all employees, regardless of the presence or absence of an employee alcoholism program, agreed that they would let a recovering alcoholic take over for them while they were on vacation. Approximately 72 percent agreed to allow the recovering alcoholic access to confidential information. Again, there were no differences in agreement on either item between respondents employed in settings with employee assistance programs and those who were not. Additionally, all respondents were slightly more accepting of the individual who had received inpatient treatment than of the individual who had achieved sobriety through Alcoholics Anonymous, although not statistically so. D.M. Tootle (1987) has reported data concerning work acceptance of the alcoholic from the survey of federal supervisors described earlier. Tootle found

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that most respondents had positive reactions to the prospect of a recovering alcoholic working in the installation and to a recovering alcoholic working as their subordinate. When asked about their confidence in the employee to carry out sensitive duties (i.e., take over for the vacationing supervisor and have access to confidential information), however, fewer than 50 percent of the respondents indicated a positive response. Only 30 percent of the sample were willing to bestow full workplace-related acceptance on the alcoholic. The data from this study suggest that discrimination against the alcoholic in the workplace may be rather subtle; although not blatantly rejected in the workplace, the alcoholic may not be entrusted with complex or sensitive duties that would provide the opportunity to earn promotions or pay increases. In summary, it appears that despite overwhelming endorsement of alcoholism as a medical condition, the alcoholic tends to be somewhat stigmatized and rejected across a wide range of settings, including the workplace where tolerance and acceptance were expected to be greatest. The 1987 Georgia study reveals somewhat more acceptance in the workplace, even on sensitive jobs, than has been evident in previous studies. The finding that the presence of an employee assistance program in the workplace made no difference in the level of acceptance, however, is rather discouraging news, particularly for those who have advocated work intervention programs as vehicles for altering attitudes. Social and Work Acceptance of the Alcoholic as a Function of Beliefs about the Nature of Alcoholism Although the expectation of alcohol educators that diffusion of the disease concept would result in unequivocal acceptance of the alcoholic has not been substantiated, social acceptance and charity to the alcoholic are somewhat moderated by one's belief about the medical nature of alcoholism (Orcutt and Cairl, 1979; Reis, 1977). Also, perhaps more important, beliefs about the moral fiber of the alcoholic appear to be significant determinants of reactions to the alcoholic. For example, R. Caetano (1987) found that, in contrast to persons who did not endorse the medical view, persons who did endorse the medical view of alcoholism were less likely to agree with the statement that they would lower their opinion of someone if they knew he or she had been an alcoholic. Data from Orcutt (1976) revealed that persons who agreed that alcoholics were both sick and morally weak (i.e., persons often classified as ambivalent) and those characterizing the alcoholic as morally weak only were more likely to admit discomfort around alcoholics than persons who did not view the alcoholic as morally deficient. In a study by Orcutt, Cairl, and Miller (1980), social rejection and perceived threat from an alcoholic were more characteristic of persons in work roles less likely to adopt a medical model of alcoholism (i.e., law enforcement personnel) than those in professions that had embraced the medical concept (i.e., medical professionals). Rejection of the alcoholic in the workplace as a function of beliefs about the

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medical and moral nature of alcoholism has received little attention. The study of supervisors in federal installations described earlier, however, contains some data relevant to the issue. Federal supervisors classified problem drinking as a physical disease, a mental health problem, a behavior problem, a lack of selfcontrol, or a health problem resulting from a lack of self-control. Respondents then answered questions regarding their acceptance of a recovering alcoholic in the workplace and questions regarding willingness to behave charitably toward the problem of alcoholism. It is evident from Table 17-1 that there is little difference among persons who classify problem drinking as a physical disease, a mental health problem, and a behavior problem in terms of social and work acceptance and willingness to make a charitable contribution to employee alcoholism programs or support the notion of health insurance coverage of alcohol treatment. However, persons classifying problem drinking as a lack of self-control, and to some extent those classifying problem drinking as a health problem resulting from a lack of selfcontrol, differ from the other three groups in that they are less accepting of the recovering alcoholic, less willing to make a charitable contribution, and less supportive of the provision of health insurance coverage for alcoholism treatment. These results indicate that aspects of the moral concept of alcoholism (i.e., that the condition results from a lack of self-control or from a lack of moral fiber) may be more important determinants of reactions to alcoholics and of a charitable orientation toward the problem of alcoholism than are beliefs about the physical disease aspects of the condition. SUMMARY There is little doubt that changes have occurred in the conceptions of alcoholism and the alcoholic over the past 25 years. Certainly the disease concept now enjoys widespread acceptance. Additionally, alcoholism is much less frequently defined strictly as a character defect or a condition of weak will than it was in the past. There is also some hint that alcoholics are less subject to the degradation and social rejection that were evident before the efforts by NCA and NIAAA to change the public's beliefs about alcoholism. Have interventions at the level of the workplace been instrumental in effecting these changes? The impact of workplace alcohol programs on attitudes is difficult to assess. Public education efforts have been widespread, and through mass media efforts persons in many walks of life have been exposed to a humane, compassionate approach to alcoholism. Certainly, this orientation has not been specific to the workplace. Because educational efforts have been implemented across so many environments, the impact of one particular effort (i.e., the workplace) is difficult to assess. Nevertheless, the data presented in this chapter suggest that the workplace has not had a particularly strong influence on attitudes about alcoholism. Data from the two Georgia polls, for example, show no differences between workers

Table 17-1 Percentage of Supervisors Who Were Accepting of the Alcoholic and Supportive of Alcoholism Programs by Classification of Problem Drinking Soc i a I Acceptance

Work Acceptance

Charitable

Willingness

Wi llingness

Wi llingness

Willingness

to socialize

to have as

to have

to give

with after

subordinate

work

represent

access to

Behavio

Willingness to make financial

Support for coverage of alcohol

agency at

confidential

contribution

national

information

to suppport

health

alcoholism

insurance

meeting

treatment by

program Classification of problem dr i nk ing physical disease

80.3

95.3

69.7

52.0

72.4

90.5

mental health 51.8

67.7

89.6

67.8

44.8

62.6

79.0

84.0

49.7

30.9

52.8

55.5

89.9

59.5

35.7

64.1

80.7

problem

78.4

92.5

behavior problem

78.0

92.1

60.2

73.5

66.0

lack of self-control health problem resulting from a lack of selfcontrol

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273

in settings with employee assistance programs and those in settings with no programs in terms of belief in the disease concept, rejection of the moral stigma associated with alcoholism, or social acceptance of the alcoholic. If these studies had been conducted before the extensive mass media campaigns to educate the public about alcoholism, the influence of educational efforts at the level of the workplace might have been more easily distinguished from other efforts. The study of federal work supervisors also calls into question the role of the workplace in promoting a compassionate and charitable orientation to the problem of alcoholism. A large percentage of these supervisors rejected the disease concept of alcoholism, endorsed the moral concept, and were unaccepting of the alcoholic in both work and social settings. Certainly, based on self-reports of beliefs and behavior, these persons were not modeling the attitudes or behavior toward alcoholics that educational groups had hoped to see modeled in the workplace. The data presented have their limitations, however, in elucidating the influence of the workplace on attitudes about alcoholism. As discussed earlier, no studies have been designed to address this specific question. Consequently, the impact of workplace alcohol programs must be inferred from data collected for other purposes. A study that measures attitudes at all organizational levels of employees before the implementation of a workplace alcohol program and at regular intervals after the implementation of each aspect of the program would give more direct evidence about the impact of such programs. Despite the positive changes that have occurred in attitudes about alcoholism, alcoholics do not now enjoy full social acceptance. In fact, the evidence indicates quite the contrary; a moral stigma continues to be attached to alcoholism, and alcoholics continue to meet with social rejection despite the widespread acceptance of the medical model of alcoholism. Several potential explanations can be offered for this occurrence. First, the "sick" role inherent in the medical model carries a negative stigma (Rule and Phillips, 1973); research has shown that sick persons are regarded as helpless, impotent, and out of control. Also, sick persons tend to remind others of their own vulnerability (Lerner and Miller, 1978). Second, and perhaps more important, alcoholics, although they are considered sick are still held responsible for their condition, and attributions of responsibility for any illness tend to elicit derogation of the sick individual (Weiner, Perry, and Majussion, 1988). According to the data presented in this chapter, beliefs about the moral responsibility of alcoholics are more important in determining reactions to the alcoholic than is the belief in the medical nature of alcoholism. These findings indicate that alcohol educators should spend at least as much of their efforts refuting the moral concept of alcoholism as they do in promoting the medical concept. The subject of this chapter has been the importance of the workplace in modifying attitudes about alcoholism. The flip side of that question is also important (i.e., do attitudes about alcoholism influence the effectiveness of workplace alcoholism programs?). Alcohol professionals have stressed the importance

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of a safe, accepting environment to reduce denial of alcohol problems and to promote an honest examination of drinking behavior and its effects (Tournier, 1985). Workplace alcohol programs are built upon this premise. Additionally, it has been speculated that attitudes about alcoholism in the workplace determine individuals' willingness to seek treatment once they have admitted to themselves that there is an alcohol problem. If employees fear repercussions from an intolerant work situation, they are not likely to pursue treatment actively. Finally, attitudes by management, supervisors, and co-workers may be very important in determining individuals' readjustment after alcoholism treatment and in determining their ability to remain sober. Again, research programs whose primary aim is the investigation of these assumptions are difficult to find. Attitudes within the workplace may very well determine the effectiveness of prevention and intervention efforts. Certainly questions related to these issues appear to need further investigation. NOTE The author acknowledges support from Training Grant T32-AA-07473 awarded by the National Institute on Alcohol Abuse and Alcoholism to support the Postdoctoral Training Program in Employee Alcoholism Research at the University of Georgia.

REFERENCES Bennett, N., and Kelley, L.S. (1987). Assessing the acceptance of the disease concept of alcoholism among EAP practitioners. Journal of Drug Issues, 17 (3), 281— 299. Blizard, P.J. (1970). The social rejection of the alcoholic and the mentally ill in New Zealand. Social Science and Medicine, 4, 513-526. Blizard, P.J. (1971). Beliefs about disease and alcoholism. Mental Hygiene, 55, 184— 189. Blum, T . C , Roman, P.M., and Bennett, N. (1989). Public images of alcoholism: Data from a Georgia survey. Journal of Studies on Alcohol, 50, 5-14. Caetano, R. (1987). Public opinions about alcoholism and its treatment. Journal of Studies on Alcohol, 48, 153-160. Cash, T.F., Briddell, D.W., Gillen, B., and MacKinnon, C. (1984). When alcoholics are not anonymous: Socioperceptual effects of labeling and drinking pattern. Journal of Studies on Alcohol, 45, 272-275. Farina, A., Holland, C.H., and Ring, K. (1966). The role of stigma and set in interpersonal interaction. Journal of Abnormal Psychology, 71, 471-478. Freeman, H.E. (1961). Attitudes toward mental illness among relatives of former patients. American Sociological Review, 26, 59-66. Freidson, E. (1966). Disability as social deviance. In M.B. Sussman (Ed.), Sociology and rehabilitation. Washington, DC: American Sociological Association. Hoffman, E., and Roman, P.M. (1984a). The effect of organizational emphasis upon the diffusion of information about innovations. Journal of Management, 7, 277-292. Hoffman, E., and Roman, P.M. (1984b). Information diffusion in the implementation of innovation process. Communication Research, 11, 117-140.

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Kilty, K.M. (1975). Attitudes toward alcohol and alcoholism among professionals and nonprofessionals. Journal of Studies on Alcohol, 36, 327-347. Kilty, K.M. (1981). Drinking status and stigmatization. American Journal of Drug and Alcohol Abuse, 8, 107-116. Kilty, K.M., and Meenaghan, T.M. (1977). Drinking status, labeling, and social rejection. Journal of Social Psychology, 102, 93-104. Lerner, M., and Miller, D. (1978). Just world research and the attribution process: Looking back and ahead. Psychological Bulletin, 85, 1030-1051. McNeil, D.W., and Janzen, W.B. (1978). Attitudes toward problem drinkers: Cognitive, affective, and behavioral intention dimensions. The International Journal of the Addictions, 22, 993-1017. Mulford, H.A., and Miller, D.E. (1961). Public definitions of the alcoholic. Quarterly Journal of Studies on Alcohol, 25, 312-320. Mulford, H.A., and Miller, D.E. (1964). Measuring public acceptance of the alcoholic as a sick person. Quarterly Journal of Studies on Alcohol, 25, 314-323. Orcutt, J.D. (1976). Ideological variations in the structure of deviant types: A multivariate comparison of alcoholism and heroin addiction. Social Forces, 55, 420437. Orcutt, J.D., and Cairl, R.E. (1979). Social definitions of the alcoholic: Reassessing the importance of imputed responsibility. Journal of Health and Social Behavior, 20, 290-295. Orcutt, J.D., Cairl, R.E., and Miller, E.T. (1980). Professional and public conceptions of alcoholism. Journal of Studies on Alcohol, 41, 652-660. Reis, J.K. (1977). Public acceptance of the disease concept of alcoholism. Journal of Health and Social Behavior, 18, 338-344. Riley, J.W. (1949). The social implications of problem drinking. Social Forces, 27, 301305. Rodin, M.B. (1981). Alcoholism as a folk disease: The paradox of beliefs and choice of therapy in an urban American community. Journal of Studies on Alcohol, 42, 882-885. Roman, P.M. (1981). From employee alcoholism to employee assistance. Journal of Studies on Alcohol, 42, 244-272. Roman, P.M. (1988). Growth and transformation in workplace alcoholism programming. In Marc Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 105111). New York: Plenum Press. Roman, P.M., and Blum, T.C. (1985). The core technology of employee assistance programs. Almacan, 15, 8-12. Room, R. (1983). Sociological aspects of the disease concept of alcoholism. In R.G. Smart, F.B. Glasser, Y. Israel, H. Kalnut, R.E. Popham, and W. Schmidt (Eds.), Research advances in alcohol & drug problems (pp. 47-91). New York: Plenum Press. Rule, B.G., and Phillips, D. (1973). Responsibility versus illness models of alcoholism. Quarterly Journal of Studies on Alcohol, 34, 489-495. Stafford, R.A., and Petway, J.M. (1977). Stigmatization of men and women problem drinkers and their spouses: Differential perception and leveling of sex differences. Journal of Studies on Alcohol, 38, 2109-2121. Tootle, D.M. (1987). Social acceptance of the recovering alcoholic in the workplace: A research note. Journal of Drug Issues, 17, 273-279.

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Tournier, R.E. (1985). The medicalization of alcoholism: Discontinuities in ideologies of deviance. Journal of Drug Issues, 15, 39-49. Trice, H.M., and Schonbrunn, M. (1981). A history of job-based alcoholism programs: 1900-1955. Journal of Drug Issues, 11, 171-198. Weiner, B., Perry, R.P., and Majussion, J. (1988). An attribution analysis of reaction to stigmas. Journal of Personality and Social Psychology, 55, 738-748.

18 EAP AND WELLNESS PROGRAM FOLLOW-UP AS PRIMARY, SECONDARY, AND TERTIARY PREVENTION STRATEGIES IN THE WORKPLACE J O H N C. ERFURT

Most employee assistance programs (EAPs) leave follow-up out of their repertoire of program procedures. Sometimes they put in aftercare and sometimes they do not. Follow-up is, more often than not, placed on the back burner of routine EAP life because most of the work of the EAP, in regard to alcoholism and substance abuse, is "up-front loaded," that is, most of the budget and energies go into case finding, problem assessment and referral, and treatment. Very little time, if any, is devoted to the crucial work of worksite follow-up with those employees who have returned to their jobs from treatment. It is during this phase of a client's life that he or she is most vulnerable to relapse and is in need of post-treatment support and monitoring. Downsizing or eliminating posttreatment follow-up is a serious mistake on the part of the EAP, and it is hoped that the information in this chapter will support that point of view. DISTINCTION BETWEEN FOLLOW-UP AND AFTERCARE EAP follow-up, done at the worksite, involves a series of post-treatment interventions with the client to ensure completion of treatment, to assist the client in maintaining his or her recovery, and to help prevent relapse. It is carried out at the workplace, not in a clinic, and involves not only monitoring the client's personal behavior at work, but also his or her work performance records during the return-to-work and recovery periods of the client's life. Aftercare is a series of post-treatment interventions that can be carried out by the treatment provider or by self-help groups (e.g., Alcoholics Anonymous). It is not usually carried out by the EAP. Aftercare usually occurs after inpatient or residential treatment or after intensive outpatient treatment. It is usually carried out away from the worksite—in a clinic or meeting facility. It is usually an

278

Employee Assistance Programs

extension of the official treatment plan. Follow-up, on the other hand, is an extension of EAP procedures at the workplace: it extends case finding, problem assessment, and referral beyond the treatment stage and onward to the returnto-work phase and the recovery period. Two points must be made about aftercare; the rest of this chapter will be spent on different aspects of follow-up. First of all, it is apparently very difficult to get clients to come to aftercare. One large treatment facility in the Detroit suburban area handled these aftercare difficulties in the following way: (1) they established a year-long aftercare program for substance-abuse patients, and when they were unable to get clients to come, they reduced the program to six months and (2) when they were again unable to get clients to come for most sessions, they reduced the program to four months, then to three months, and finally to one month. Reducing the time of aftercare, and thereby making the process more convenient for the provider rather than for the client, is hardly helpful to the long-term success of the treatment process. Second, in a study conducted by A. Foote and J.C. Erfurt (unpublished) of aftercare in Atlanta, Georgia, comparing EAP clients who stayed in aftercare with those who did not, revealed no significant differences across any of the outcome measures, which included readmissions for substance-abuse treatment, absenteeism, sickness and accident claims, and health care claims. THE NATURE OF FOLLOW-UP Follow-up, compared to aftercare, is quite a different story. By follow-up, we mean persistent, outreaching, posttreatment follow-up contacts with clients to provide love ("tough love"), support, positive reinforcement when appropriate, and a no-nonsense approach to help him or her with his or her problem. Table 18-1 contains a detailed definition of follow-up that was developed in August 1987, for use in a series of training programs. This definition is currently being used to train health care professionals and paraprofessionals to perform the follow-up phase. The happy thing about follow-up, unlike aftercare, is that follow-up works— works in the sense that EAPs (especially those that are on-site at the workplace) are in a position to reach their clients, whereas treatment agencies are not. Followup works in a whole series of different environments and for different types of programs (e.g., wellness programs as well as EAPs). The remainder of this chapter presents follow-up data from several different studies including studies in General Motors Corporation, Ford Motor Company, Western Electric, the Store-Workers' Union, and several unidentified companies. Some of these studies were quantitative, some were qualitative, and some were both. FOLLOW-UP AS VARIOUS TYPES OF PREVENTION STRATEGIES Table 18-2 presents well-accepted definitions of primary, secondary, and tertiary prevention. Table 18-3 provides some key examples of how follow-up

EAP a n d Wellness Program Follow-up

279

Table 18-1 Health Service Follow-up "Follow-up" in health service delivery systems includes regular, routine contacts with clients or patients who have health risks that need to be controlled over long periods of time, chronic diseases that need to be treated for long periods, or other health-related needs and objectives that require on-going attention and monitoring. These contacts are carried out by mail, by phone, and in person. The function of these client/patient contacts is three-fold--(l) educational, (2) motivational, and (3) on-going assessment and evaluation. The purposes of these contacts include: (a)

Inducing the client/patient to start the health care or health promotion action called for,

(b)

Insuring that he/she carries through on the plan of treatment or health promotion program that was recommended, and

(c)

The on-going prevention of false starts, noncompliance with prescribed treatment, and relapse from the desired set of health behaviors.

The content of client/patient contacts includes information retrieval, information dissemination, monitoring of personal health risk factors, and the implementation of strategies to move the patient/client toward on-going positive health behaviors. Health service follow-up also includes periodic contacts (by mail and by phone) with the persons or groups that provide the health care or health promotion to the clients/patients in the follow-up caseload. This component of the overall follow-up effort provides corroborative health information regarding the client/patient's case, lends support to the health providers' objectives, and lends an added dimension to the evaluation of the client/patient's overall progress. Health service follow-up is, intrinsically, long-range in nature and generally persistent in character. It is carried out with tender loving care, but always with a professional and "no nonsense" delivery. In the long run, follow-up is the blending of care-giving and care-receiving into a life-long partnership of good health and well-being, for all parties involved. --John C Erfurt & Andrea Foote Worker Health Program Institute of Labor & Industrial Relations The University of Michigan August 1987 procedures might be used as strategies for primary, secondary, and tertiary prevention. If all of the employees in a work force were routinely screened for health-risk factors and were followed at least once every six months between screenings conducted every five years, all three of these methods of prevention would be undertaken. The follow-up system would be dealing with some people with few or no risk factors and attempting to prevent any such risks from developing. The system would also deal with clients who have developed (or are developing) risk factors and would attempt to avoid the transition of these

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Table 18-2 Definitions of Primary, Secondary, and Tertiary Prevention PRIMARY PREVENTION;

• Reducing the incidence of a problem within a specified population. • T A R G E T : The entire population, or those "at risk" of developing the problem. • PREVENTION OF THE PROBLEM BEFORE IT DEVELOPS.

SECONDARY PREVENTION:

• Reducing the prevalence of the problem, by reducing its duration. • T A R G E T : Individuals with the problem, preferably early in its development. • EARLY DETECTION OF PEOPLE WITH THE PROBLEM.

TERTIARY PREVENTION;

• Reducing severity of the problem and disability of the individual with the problem; rehabilitation. • T A R G E T : Individuals with the problem, at the middle or late stages of development. • TREATMENT AND FOLLOW-UP FOR PEOPLE WHO HAVE A WELL-DEVELOPED PROBLEM.

Table 18-3 Follow-up as a Method of Primary, Secondary, and Tertiary Prevention EXAMPLES: • PRIMARY PREVENTION:

Wellness program follow-up with individuals who have no known "risk factors," to prevent the development of such risk factors; e.g., high blood pressure, heavy drinking, overeating, etc.

• SECONDARY PREVENTION:

Wellness program follow-up with individuals with known "risk factors," to prevent the development of life-threatening disease; e.g., follow-up with hypertensives to prevent heart disease, follow-up with heavy drinkers to prevent the development of alcoholism, etc.

• TERTIARY PREVENTION:

EAP follow-up with clients who have been treated for substance abuse or mental health problems, to prevent relapse and insure continued recovery.

risks into life-threatening or job-threatening diseases or behavioral problems. Here the objective would be to control or eliminate these risks. Finally, the system would be dealing with employees who have been treated for life-threatening (or job-threatening) diseases or problems; the task here would be to help reduce relapse and to ensure an ongoing, successful recovery.

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THE IMPACT OF FOLLOW-UP ON WELLNESS PROGRAMS AND EAPs The primary objective of what have come to be called wellness or health promotion programs is to prevent or reduce risk factors that lead to early death or disability—especially cardiovascular diseases and cancer. Wellness programs are, in essence, designed to prevent diseases or health problems that are linked to inappropriate or risky lifestyle behaviors—such as smoking, overeating, excessive drinking, and too little exercise. Although the content of wellness programs varies from company to company, the most comprehensive programs usually deal with six different areas of disease prevention and health promotion: blood pressure control, cholesterol control, weight loss, smoking cessation, physical fitness (exercise), and stress management. Our studies of wellness programs have shown consistent findings linking follow-up to increased program effectiveness, with regard to blood pressure control, weight loss, and smoking cessation (Foote and Erfurt, 1983; Erfurt et al., 1989; Erfurt, Foote, and Heirich, 1989a). There is some evidence that followup is also related to enhanced effectiveness in the areas of physical fitness and stress management (Erfurt, Foote, and Heirich, 1989b). Finally, new programs in the area of cholesterol screening show a similar positive impact of follow-up on cholesterol control (Erfurt, Foote, and Heirich, 1989c). The first wellness programs to demonstrate the relationship between followup and program effectiveness were blood pressure control programs. Table 184 shows the impact of follow-up on blood pressure control in a four-plant, quasiexperimental study (Erfurt et al., 1989; Erfurt and Foote, 1984). In this study, the employees at all four plants were screened for high blood pressure in 1978, and were rescreened in 1981. At site 1, there was no follow-up at all for three years, and at sites 2 , 3 , and 4, there were varying degrees of follow-up; site 4 was the most ambitious, offering on-site treatment for hypertension (high blood pressure) as well as on-site follow-up. Table 18-4 shows that, without follow-up, there was no significant increase in the percentage of employees with their blood pressure under good control, but in the three follow-up sites, the percentage under good blood pressure control was nearly three to four times greater than at the control site (without followup). Since the mid-1970s until the present time, in worksite hypertension control programs, follow-up has been demonstrated to work time and time again (Wilber and Barrow, 1969; Foote and Erfurt, 1984). Follow-up has been recently related to improved program participation in the areas of weight loss and smoking cessation. Table 18-5 shows another fourplant, quasi-experimental study. In this study, only sites 3 and 4 involved followup with all smokers and employees 20 percent overweight or more (Erfurt et al., 1989). Site 1 was the control site, and site 2 was the health education site, involving only screening, use of the plant media, and health improvement classes.

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Table 18-4 The Impact of Follow-up on Blood Pressure Control ADEQUACY OF BP CONTROL AT SCREENING (S) AND AT TIME OF FINAL CONTACT (FC) , FOR ALL HYPERTENSIVE EMPLOYEES (EXCLUDING FALSE POSITIVES) AT EACH SITE_

BP CONTROL

STATUS:

Si te 1

Site 2

Site 3

No Follow-Up

Semi Annual Follow-Up

Follow-Up Based on BP Status

S

FC

1978

Total Caseload Minus False Positives

1981

S

FC

1978

1981

S

• Not under treatment

l\S%

16%

kk%

•

Treated, BP u n c o n t r o i l e d

16

36

1*1

• Near c o n t r o l (BP below 160/95)

U\

26

• BP i s c o n t r o l led (BP below 1 W 9 0 )

21 100%

FC

1978

773

296

|

. 1981

Site k In-Plant Treatment S

FC

1978

561

1981

120

63%

6%

62%

1%

10

13

7

11

2

18

26

10

33

11

13

22

2**

56*

\h

5k*

16

8V

100%

100%

100%

100%

100%

100%

100%

8%

*Tnrrease in percent under control was siqnificant (p<.0011.for Sites 2,3,.and 4, hut not for .Site 1. •,

SOURCE? "hypertension Control at the Work Site: Comparison oT Screening and Referral Alone, Referral and Follow-Up, and On-Site Treatment," by Andrea Foote and John C Erfurt, Ncv; England Journal of Medicine, 308 (April 1983).

Program participation in the follow-up sites was seven and five times higher than at the nonfollow-up sites, for areas of weight loss and smoking cessation, respectively. Subsequent analyses of these data indicate that the actual results of program participation were more successful in the two follow-up sites—this was true for weight loss, smoking cessation, blood pressure control, and physical fitness (Erfurt, Foote, and Heirich, 1989b). With regard to the ultimate impact of follow-up on end-organ disease and premature death, Table 18-6 shows the impact of follow-up on cardiovascular morbidity and morality (Alderman, Madhavan, and Davis, 1983). In this study of department store workers, 150 hypertensive employees received worksite treatment and persistent follow-up. One hundred and ninety-four similar hypertensive employees got their treatment through community physicians and received no worksite follow-up. After eight and one-half years, morbidity due to cardiovascular disease and mortality (due to all causes) was decreased by nearly 50 percent among the follow-up group, compared to the community treatment group. Table 18-6 shows that with a caseload of 500 hypertensives, the estimated net benefit to the company would be over $174,000. Thus, this table is for everyone—both the humanitarians and the cost-benefit specialists. Thus follow-up has been shown in several wellness studies to have an impact on program outcomes. What about EAP? Does follow-up show an impact in this

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Table 18-5 The Impact of Follow-up on Wellness Program Participation (Weight Loss and Smoking Cessation) CUMULATIVE PARTICIPATION BY OVERWEIGHT AND SMOKING EMPLOYEES, RESPECTIVELY, IN WEIGHT LOSS AND SMOKING PROGRAMS (OVER THREE YEARS OF STUDY) Cu muiative Participation in Program Interventions* Weight Loss

Site 1 (Control) Site 2 (Health Education) Site 3 ( F o l l o w - u p )

mm

Smok ling Cessation

Yr 1

Yr 2

Yr 3 "

Yr 1

Yr 2 " Yr 3 "

<]%

<1%

<1%

<1%

<1%

<1%

7%

7%

7%

9%

9%

9%

15%

47%

53%

12%

42%

47%

8%

38%

44%

Site 4 ( F o l l o w - U p / P l a n t Org..) 6%

46%

56%

T h e denominator for weight Joss participation was the number of overweight employees (20% or more above ideal weight) identified at screeninig and still employed at the plant at the end of the respective year. The denominator for smoking cessation participation was smokers identified at screening and likewise still at the plant at the end of the respective year. **Differences in cumulative participation at the end of Year 2 and Year 3 between Sites 1 and 2 and Sites 3 and 4 were statistically significant for all comparisons, p<.001, based on a t-test. S O U R C E : "Improving Participation in Worksite Wellness Programs: Comparing Health Education, A Menu Approach, and Follow-Up Counseling," by John C Erfurt, Andrea Foote, Max A. Heirich, and Walter Gregg. Submitted for publication to the American Journal of Health Promotion.

area? One study has suggested that follow-up does produce an impact in the area of substance abuse. Table 18-7 shows multiple regression analyses from a study conducted in a large manufacturing firm (Foote and Erfurt, 1988). In this study, all EAP clients entering the program during the first year of the project were randomized into a special follow-up group or into a control group which received little or no follow-up. Although the follow-up procedures with the experimental group did not go smoothly and were far from perfect, the number of follow-up contacts per client was five times higher among the experimental group than for the control group. Furthermore, in terms of direct follow-up contacts with clients (by phone or in person), the ratio was seven to one, in favor of the special follow-up group. The multiple regression analyses shown in Table 18-7 show that being in the follow-up group (compared to being in the control group) was related to less relapses (i.e., less post-treatment hospitalizations for substance abuse), less substance-abuse disability, and less treatment costs for substance-abuse and mental

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Table 18-6 The Impact of Follow-up on Cardiovascular Morbidity and Mortality COST-BENEFIT OF WORKSITE TREATMENT OVER COMMUNITY TREATMENT FOR HIGH BLOOD PRESSURE, DUE TO REDUCED MORBIDITY AND MORTALITY, OVER 8 £ YEARS BLOOD PRESSURE TREATMENT CHOICE: WORKS ITE TREATMENT With Follow-Up

• CVD HOSPITALIZATIONS AND DEATHS,

per

100

person-years

• NON-CVD HOSPITALIZATIONS AND DEATHS,

per

100

person-years

• RATIO OF OBSERVED TO EXPECTED MORTALITY

(all

causes)

• ESTIMATED COST SAVINGS FROM R E D U C E D C V D , over 82 years • WORKSITE TREATMENT COSTS, over 82 years • N E T BENEFIT • N E T ANNUAL BENEFIT

*p<.05

COMMUNITY TREATMENT NO Follow-Up

% REDUCTION

(N=5 0 0)

(N=194)

3.0

5.4

44% *

8.1

9.4

14%

1 .05

48% *

.55 SI ,058,250

—

—

S884,000 5174,250

— —

— —

S20,500

--

--

**p<.01

Source; Michael Alderman, Shantha Madhavan, and Toni Davis. Presented at the National Conference on High Blood Pressure Control, Washington, D.C., April 1983.

health problems, after controlling for other variables in the equations. Therefore, with regard to all of the studies of follow-up that we have investigated thus far— involving hypertension control programs, wellness programs, and EAPs—we have seen some significant and dramatic results in the positive direction. TERTIARY PREVENTION STRATEGIES (FOLLOW-UP INTERVENTIONS) AS ORGANIZATIONAL INTERVENTIONS Although the type of follow-up discussed to this point has been focused on one-to-one contacts with clients and employees, we also see follow-up strategies as an organizational set of interventions. Three examples are presented to show how tertiary prevention, in the form of follow-up, can be used to do more than just to deal with individuals; it can be used to change the organizational structure of the company, division, or plant. Example 1 In one company, when employees went through the medical department upon returning to work from treatment, those with a substance-abuse diagnosis were referred by the medical department to the plant EAP to establish a "return-to-

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Table 18-7 The Impact of Follow-up on EAP Clients (Substance Abusers) REGRESSION OF OUTCOME MEASURES ON PREDICTOR MEASURES, BY EAP COUNSELOR ASSESSMENT OF PROBLEM OUTCOME MEASURE

EAP Counselor Assessment of Client Problem

SUBSTANCE ABUSE DISABILITY

ALCOHOL/DRUG/ MENTAL TREATMENT COSTS

Substance

Substance Abuse

NO. OF SUB, ABUSE H6SP*S Substance Abuse

BETA COEFFICIENTS FOR: -.06 -.03 Age -.05 .12* .00 .13* Race (Black) .14* .12* Stage of disease (chronic) .04 .12** Mo. of follow-up visits .13** .03 -.11**) -.13* In Special Follow-Up group -. 12 ** | .20* .21* 1904 sub. abuse Tx/hosp's -2 .10 .11 .02 R *p<.05 **p<.10 SOURCE; "EAP Follow-Up as a Relapse Prevention Strategy," by Andrea Foote and John C Erfurt. Final Report to NIAAA, Grant # RO1-AA06567-03, from the Worker Health Program, Institute of Labor & Industrial Relations, The University of Michigan, May 1988.

(

• • • • • •

work and follow-up plan" with the EAP team member. As usual in all EAP referrals, accepting the medical department's referral to the EAP is completely voluntary on the employee's part. Nonetheless, the apparatus was put into place, and in most cases, the alcoholic client does show up at the EAP and becomes part of the program's caseload. Example 2 In another location, we asked the company to change an organizational policy to allow the wellness program (via the medical department) to call employees in off the floor for follow-up (postscreening) interventions. In order to see over 90 percent of the clients in the wellness caseload, we found it necessary to arrange for people to come in off the floor (on company time) in about 40 to 50 percent of the cases. About 50 to 60 percent of the cases come in on their own because of letters and phone calls to their homes. But we chose not to leave out those clients who do not come in on their own, since they are the people most often in need of follow-up services. Again, coming into the wellness office from off the floor is strictly voluntary on the part of the employee, but we find that most of them will comply with this type of request. Also, in most cases, confidentiality is preserved since the client's foreman does not need to know why the employee is being called into the medical department.

286

Employee Assistance Programs

Example 3 Finally, we needed to establish for both the EAP and the wellness program the concept of routine, post-treatment, on-site, long-range follow-up, involving supervisory and union personnel, as well as program staff and clients. All of these individuals needed to be involved in order to ensure effective follow-up procedures and to preserve client confidentiality so that improper questions would not be raised about why employees were coming in and out of the medical department—for EAP and wellness program purposes. This type of policy implementation takes a major organizational effort. Fortunately, it was very successful for the wellness program follow-up procedures, and we experienced success rates in the 80 to 90 percent range of follow-up participation. Unfortunately, we were less successful in the EAP follow-up effort, and, as a result, our success rates were in the 40- to 50-percent range, regarding follow-up participation. TERTIARY PREVENTION STRATEGIES Wellness Treatment and Follow-up Leading to Primary Prevention Strategies Tertiary prevention strategies often lead to primary prevention strategies or result in organizational changes which, in turn, result in primary prevention. This happened in two of the automobile plants studied—both in terms of qualitative and quantitative analyses. From the study of these two plants come three examples of the above in the area of wellness programming. Wellness Example 1. An on-site weight loss program, established at both of the plants, was quite successful, reaching up to 56 percent of the overweight population. When a sizeable proportion of the work force learned to eat more healthful and appropriate foods, they requested and then demanded that the plant cafeteria serve more healthful varieties of food. This led to the establishment of a cafeteria committee, to which our program dietitian became a chief consultant. Lobbying by this committee led to changes in cafeteria policy and menus, and also to changes in the types of foods being offered in the plant vending machines. Wellness Example 2. In a second example, an on-site smoking cessation program led to a change in the smoking policy, which restricted the area in which employees could smoke. In this scenario, the smoking cessation clients began saying to their supervisors and union representatives that "you've encouraged us to stop smoking, and we've stopped smoking and we've lost weight. Now, we're going to cafeterias that provide unhealthy food and we're working in places where people smoke on the job!" And to a great extent, the requested changes were made. Wellness Example 3. Finally, in one of the two plants where there were followup activities for blood pressure, weight loss, and smoking cessation, a walking

EAP and Wellness Program Follow-up

287

Table 18-8 Long-Range Follow-up and Tracking of EAP Clients in One Large Company, on the Basis of Health Care Claims

Costs for treatment of alcohol, drug, or mental problems Costs for all other medical problems S O U R C E : "Health Care Cost-Containment Through Worksite Wellness Programs," by John C Erfurt and Andrea Foote. Chapter Two in EAP Research: An Annual of Research and Research Issues,,. Volume II; Troy, MI: Performance Resource Press, Inc., 1988.

club was established to foster physical fitness. Eventually, nearly 20 percent of the work force participated in the walking club, which included walking contests, T-shirt awards, and so on. Many of the employees in the wellness program took part in this venture to keep their blood pressure under control, to maintain their success at weight loss, and to reduce more effectively the stress in their lives. EAP Treatment and Follow-up Leading to Major Organizational Change Tertiary prevention strategies leading to major organizational change also occur in the area of EAPs, as well as in the area of wellness programming. The following three examples demonstrate this kind of phenomenon. All of these cases revolve around EAP issues, and all took place in one large manufacturing company. EAP Example 1. Table 18-8 is commonly referred to as the "monster chart" since it shows what can happen to health care claims when substance abuse leads to systems abuse (Erfurt and Foote, 1988). This study shows the results of EAP client tracking and follow-up for three years prior to program entry (year 0) and four years after program entry. The outcome measures in this chart are medical

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Employee Assistance Programs

Table 18-9 Major Organizational Change in Both Basic EAP Structure and Policy Regarding the Utilization of Substance-Abuse Treatment Benefits • CHANGE IN BASIC EAP STRUCTURE: FROM: Referral CLIENT

Referral >

> EAP

TREATMENT

T0_: Referral CLIENT

Referral

> EAP

Referral

> CDR*

>

TREATMENT

• CHANGE IN POLICY RE TREATMENT BENEFITS In order to obtain benefits for substance abuse treatment, the client must move through the CDR (Central Diagnostic and Referral Agency).

•Central Diagnostic and Referral Agency.

benefit costs—those for the treatment of substance-abuse and mental health problems, and those for all other medical problems. The data in this table demonstrate an EAP system that has failed—they show where both kinds of health care costs go way up after program intervention, and they stay consistently high after four years of supposed post-treatment recovery. This is substance abuse leading to systems abuse, whereby one of the clients in this chart actually went to inpatient residential treatment sixteen different times in five years. This experience with substance-abuse treatment and the lack of adequate follow-up resulted in a complete organizational change, in both the EAP structure and the nature of the treatment benefits received by the employees in this company. Table 18-9 shows these two dramatic changes. The structure of the EAP was changed from the employee going to the EAP for direct referral to treatment to the client going to the EAP and then being first referred to a central diagnostic and referral (CDR) agency, which makes the diagnosis and refers the client to treatment or not, as the case may be. The change in policy regarding employee treatment benefits now dictates that an EAP client (or any employee seeking treatment for substance abuse) must move through the CDR system to obtain substance-abuse treatment benefits after the first treatment occasion incurred by the employee. A tertiary prevention strategy led to these organizational changes—

EAP and Wellness Program Follow-up

289

to prevent substance abusers from abusing the system and, at the same time, to assist these clients in improving their chances for true recovery. EAP Example 2. The second example is a case in which the EAP administrator found out through the follow-up and program evaluation system that company supervisors were missing about 50 percent of the potential EAP caseload clients. The data reveal that 7.6 percent of the plant employees were seen as EAP clients (a group utilizing about 25 percent of the total sickness and accident benefits paid in the plant) and that another 7.2 percent had the same or greater utilization of sickness and accident benefits as the EAP clients, but were not seen as EAP clients because of a failure of the system to refer these employees into the program. This revelation led to an organizational effort by both management and the union to get supervisors to do their job more effectively and to enforce progressive disciplinary procedures, leading to more supervisory referrals into the EAP. EAP Example 3. Still another case in which EAP follow-up led to a major organizational change is illustrated by a plant in which from 13 to 15 percent of all plant employees were responsible for from 70 to 75 percent of all sickness and accident claims. Less than 20 percent of all the employees accounted for almost 75 percent of all disability payments! This insight led to the company-wide establishment of an absenteeism control program, which routinely monitors employee attendance, counsels employees with minor attendance problems, and refers those with major attendance problems to the EAP. Also, in cases where there is the slightest hint of substance-abuse or mental health problems, the employees in question are referred from the attendance counselor to the EAP counselor. OVERCOMING "POLITICAL TABOOS" IN ACHIEVING EAP-WELLNESS PROGRAM OBJECTIVES When doing research in the area of worksite health, researchers always face political issues. Political issues should be considered as key variables in these research ventures. When conducting action or applied research, not only must certain political taboos be taken into consideration, but also the way to remove or change the nature of such political taboos must be addressed. The following six examples of political issues we encountered in our research—three come from the EAP area and three from the wellness area.

EAP Examples Example 1. The first example is a political taboo against sending program materials to the client's home—or being able to make phone calls to the home— even with a consent form signed by the client which allows the program to do these things. Why does this political taboo exist, one might ask. The claim is that the employee's spouse might open the client's letter—even though to do so would be a felony—and thereby confidentiality might be breached.

290

Employee Assistance Programs

This taboo provides a tremendous barrier to effective program procedures, since many of the reluctant clients can be reached successfully only at home. If a program is only going to deal with the easy-to-work-with clients, then the program is not earning its keep. In order to involve the less-than-easy-to-workwith clients—especially in follow-up)—the program must reach out to the person at home, as well as at the worksite. Wellness programs sometimes face similar political problems in regard to home mailings; the following incident reveals how important this can be to program success. One client of a wellness program came into the wellness office at his plant and claimed that his wife had opened the letter that the program had sent to his home about his high blood pressure and high cholesterol. He seemed very annoyed by this occurrence, and he explained that his wife had insisted he see the family doctor about these two health problems. The client was angry with the wellness counselor and blamed the program for his dilemma. The wellness counselor immediately pointed out to him that he had signed a consent form, allowing her to mail that follow-up notice to his home. At this reminder, the client exclaimed, "Yeah, now I gotta go to the doctor!" Of course, that is exactly what we wanted to happen. Example 2. In some companies there is a political taboo about calling employees off the plant floor for EAP follow-up purposes because the action might violate confidentiality, i.e., somebody will know that the employee is going to the EAP office. However, if people were that worried about being seen going into the EAP office, then nobody would ever get into the EAP office, unless it was located 30 miles offsite. Furthermore, it is possible to call an employee to the medical department or personnel department (depending on where the EAP office is located), without identifying the EAP as the reason. The client's supervisor and union representative have no need to know why the client is being called off the floor. So at least the appearance of confidentiality is maintained, and in most instances, this is what really counts. Example 3. Still another political taboo in the EAP area has to do with employees working in breweries. The labor unions involved with these employees were able to win their demand that employees be allowed to drink beer during their work breaks and lunch hour, on the grounds that they should be able to share in the fruits of their labor. This, of course, is counter to the objectives of the EAP, which discourages excessive alcohol consumption, especially alcohol consumption during working hours. But once a union has negotiated a "benefit," it is extremely difficult to get that benefit changed or rescinded—even if it conflicts with other union-supported objectives, such as the EAP. Ways to overcome this type of situation are considered later in this chapter. Wellness Examples The field of wellness also has its political taboos, and these often provide barriers to effective wellness programming. The following are three examples of political taboos that affect the wellness arena.

EAP and Wellness Program Follow-up

291

Example 1. With regard to wellness, there exists in many companies a labor union taboo against removing cigarette machines from the worksite; this was a bargained-for employee benefit, and removal would constitute discrimination against workers who smoke. Even though both union and management are promoting smoking cessation programs and smoking policies that are more and more restrictive, there remains a taboo about taking the cigarette machines out of the workplace areas. Like the drinking of beer in the breweries, worksite cigarette machines were a negotiated benefit and are difficult to remove, even though cigarette smoking is detrimental to the employee's health. Example 2. In some companies, there has been a political taboo against allowing company medical department staff members to be notified of an emergency blood pressure level during wellness screening operations conducted by outside vendors. Normally, fewer than 1 percent of the employees will have such an emergency level (where their blood pressure readings are so high that they require immediate attention). Nonetheless, we have found opposition to allowing the wellness program to notify the medical department, on the grounds that this would violate confidentiality, since someone other than the wellness program staff would know the employee's blood pressure readings. Even though medical staff are pledged to confidentiality of medical records, this can be a political issue. This issue has been overcome by getting labor, management, and medical personnel to agree on a wellness objective—i.e., to place the life of a client above other considerations, since clients needing an emergency referral are often at risk of sudden death, or of having a heart attack or stroke. Once all parties agree on a larger objective, then it becomes more difficult for one of the parties to object politically to changes in procedures that are necessary to meet that larger objective. This is one principal rule or strategy for overcoming political taboos and changing the way that things are usually done. Another strategy is to implement or start something that most parties agree to in order to get a related taboo changed. For example, it is easier to launch a smoking cessation program in the plan than it is to restrict the work locations in which the employees can smoke, or to remove cigarette machines from the workplace. Once a stop-smoking program has been successful, however, with widespread employee participation, it becomes easier for labor and management to address such issues as smoking location restrictions and the removal or reduction of cigarette machines on company premises. Example 3. Throughout industry, there is widespread opposition to drug testing—this is, mandatory, random drug testing of employees at the worksite. As a result, some—but not many—companies have been reluctant to use less controversial methods of screening, such as wellness screening. These reluctant companies have said that machines for measuring blood cholesterol should not be used in worksite screenings because, although these cholesterol programs are not testing for drugs or alcohol, they may give the appearance of testing for

292

Employee Assistance Programs

drugs and may therefore lead to a bad political reaction on the part of the work force. Again, this barrier has been overcome by getting labor, management, and medical personnel to agree on the larger objective of cholesterol control. The current high visibility and widespread promotion of cholesterol screening on the part of the federal government (because high blood cholesterol is a major factor in causing heart attacks and premature death) has been very helpful in achieving such agreement. One program overcame this political taboo by, among other things, changing the name of the procedure from "screening" to "appraisal." The word appraisal was less threatening than the word screening, and the wellness program became officially known as the "health risk appraisal program."

RELATIONSHIP BETWEEN WELLNESS PROGRAMS AND EAPs REGARDING PRIMARY, SECONDARY, AND TERTIARY PREVENTION Wellness programs set up for secondary and tertiary prevention can lead to primary prevention with regard to alcoholism, drug abuse, and mental health problems. The most basic primary prevention of substance abuse is summarized by Mikhail Gorbachev (1987) in his book, Perestroika: New Thinking for Our Country and the World: "The most reliable way to get rid of such an evil as alcoholism is to develop the sphere of recreation, physical fitness, sport, and mass cultural activities, and to further democratize the life of society as a whole.'' I certainly agree with Mr. Gorbachev, and I believe that as wellness program follow-up becomes more and more successful among the population of a work force, the more successful will be the company's efforts to prevent late-stage substance-abuse and chronic mental health problems. A major difference between wellness programs and EAPs is that, in the former, case finding is carried out by means of wellness screening or health risk appraisal. Thus, risk factors and addictions such as smoking or overeating are detected directly through the screening process. In the case of EAPs, case finding is normally carried out in an indirect manner, except for those companies engaged in random drug or alcohol testing. The usual case-finding technique is to find cases by detecting impaired work performance. Unlike wellness programming, EAP case finding is not usually carried out by program staff, but by company supervisors and union representatives. When this case finding is carried out correctly, detected impaired work performance leads to a referral to the EAP, which, in turn, assesses the employee's underlying behavioral or medical problem. The EAP is then in a position to refer the client to an appropriate source of treatment or service in the community. But the work performance criterion is the major factor in case finding and this becomes the major criterion for what constitutes a successful recovery. Although there are basic differences between wellness programming and em-

EAP and Wellness Program Follow-up

293

Table 18-10

The Relationship between Wellness Variables (Blood Pressure and Smoking) and Alcohol Consumption MEAN SYSTOLIC AND DIASTOLIC BLOOD PRESSURE AND CIGARETTES PER DAY, BY LEVEL OF ALCOHOL CONSUMPTION, CHICAGO WESTERN ELECTRIC COMPANY (1899 white males

free of definite CHD and ages 40-55 in 1957)

Alcohol Consumpt ion • Former Dri nker • Non-Drinker • -6

N

Mean Systolic BP

67 77 841 332 208 109 148 72 45

135.0 132.4 132.7 134.8 137.0 137.9 139.1 141.9 147.8

Mean Mean D iastoli c Cigarettes BP Smoked / / / / / / / / /

84.9 84.9 85.8 86.8 88.8 88.9 89.1 90.7 95.5

13.1 3.1 9.5 10.5 10.9 13.5 12.2 16.2 18.9

SOURCE: Dyer, et al., "Alcohol Consumption, Cardiovascular Risk Factors, and Mortality in Two Chicago Epidemiologic Studies," Circulation 56:6 (Dec. 1977), 1067-74.

ployee assistance programming, the relationship between wellness and EAP variables is well established. Table 18-10 shows the direct relationship between alcohol consumption (drinks per day) and both blood pressure (systolic and diastolic) and the mean number of cigarettes smoked per day (Dyer et al., 1977). Therefore, wellness program screening and follow-up can lead to the secondary prevention of alcoholism, in terms of early detection of drinking problems. Finding employees with high blood pressure usually means finding a cohort of drinkers who do not yet have a seriously impaired work performance record. The relationship between hypertension (high blood pressure) and absenteeism has also been well established. Table 18-11 shows a study from one company that indicates that hypertensives are absent from work 12 to 30 percent more often than employees with normal blood pressure (Foote and Erfurt, 1982). Thus, employees with high blood pressure are more likely to have a somewhat more negative work performance record than employees with normal blood pressure. Finally, Table 18-12 shows the relationship between two key wellness variables—hypertension and smoking—and two key EAP variables—health care costs and disability (sickness and accident) costs (Erfurt and Foote, 1988). This table shows that the normotensive nonsmoker has the lowest health care and disability costs, whereas the hypertensive smoker has more than twice the health care and disability costs as the normotensive nonsmoker. These and other data lead to the conclusion that hypertensives and smokers tend, on the average, to have more attendance and health problems than do normotensives and nonsmokers. Furthermore, many wellness clients need to be referred to the EAP for

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Table 18-11 The Relationship between Hypertension (High Blood Pressure) and a Major Work Performance Measure (Absenteeism) PERCENT OF EXCESS ABSENTEEISM AMONG HYPERTENSIVES (HIGH BLOOD PRESSURE) COMPARED WITH NORMOTENSIVES (NORMAL BLOOD P R E S S U R E ) FORD MOTOR COMPANY PLANTS:

PERCENT EXCESS ABSENTEEISM AMONG HYPERTENSIVES

PLANT # 1

, , , , . 30%

PLANT # 2

28%

PLANT #3 . . . . . . . . . . . . . . . . . . . 12% PLANT # 4

29%

SOURCE: Hypertension Control in the Work Setting, Final Report on the University of Michigan-Ford Motor Company Demonstration Project/ by John C Erfurt and Andrea Foote. Ann Arbor, MI: Worker Health Program,, Institute of Labor and Industrial Relations, The University of Micjhigan, 1982.

Table 18-12

The Relationship between Two Wellness Variables (High Blood Pressure and Smoking) and Health Care Costs and Disability Costs IMPACT OF HYPERTENSION AND SMOKING ON HEALTH INSURANCE COSTS AMONG FORD MOTOR COMPANY EMPLOYEES IN FOUR MANUFACTURING PLANTS . , Annual Average Costs

Normotensives* Nonsmokers

Smokers

Hypertensives* 'r Nonsmokers Smokers

for 1977-198!:

(783)

(677)

(851)

Health Care (BC/BS) Costs

$312

$^56

$503

$66^

$252

$362

$367

$551

$56^

$818

$870

$1215

Disability (S6A)

Costs

Total Health Care Costs

(628)

•Matched on race, sex, and age. SOJRCE: "Health Care Cost-Containment Through Worksite Wellness Programs," by John C Erfurt and Andrea Foote. Chapter Two in EAP Research: An Annual of Research and Research Issues, Volume II; Troy, MI: Performance Resource Press, Inc., 1988.

early-stage substance-abuse or mental health problems, or early-stage work performance problems. On the other hand, EAP clients are often in need of a good exercise program or intensive nutritional counseling because they have neglected exercise and good dietary habits during their days of drinking and depression. These EAP clients thus need to be referred to the wellness program for treatment

EAP a n d Wellness Program Follow-up

295

of a different kind—a treatment that leads to major lifestyle behavior changes, eventually to an overall healthier existence. It is through this process of cross-program referral (from wellness to EAP) that tertiary prevention follow-up systems can result in the prevention, or at least in the early detection, of alcohol, drug, and mental health problems. Similarly, through cross-program referral from EAP to wellness, tertiary prevention followup systems can lead to basic lifestyle changes in the areas of improved physical fitness and beneficial dietary habits. Thus, operationally speaking, primary, secondary, and tertiary prevention strategies can be highly interrelated through the dual process of wellness and EAP follow-up at the workplace, in a comprehensive health and assistance program that follows employees throughout their career in the company.

REFERENCES Alderman, M.H., Madhavan, S., and Davis, T. (1983a). The impact of worksite hypertension treatment on cardiovascular disease occurrence. Paper presented at the National Conference on High Blood Pressure Control, Washington, DC. Alderman, M.H., Madhavan, S., and Davis, T. (1983b). Reduction of cardiovascular disease events by worksite hypertension treatment. Hypertension, 5 (supp. V), V. 138-V. 143. Alderman, M.H., and Stormont, B. (1979). Work site vs. community based antihypertensive care: A controlled trial. Preventive Medicine, 8, 123. Dyer, A.R., Stamler, J., Paul, O., Berkson, D.M., Lepper, M.H., McKean, H., Shekelle, R.B., Lindberg, H.A., and Garside, D. (1977). Alcohol consumption, cardiovascular risk factors, and mortality in two Chicago epidemiologic studies. Circulation, 56 (6), 1067-1074. Erfurt, J . C , and Foote, A. (1984). Cost-effectiveness of worksite blood pressure control programs. Journal of Occupational Medicine, 26, 892-900. Erfurt, J . C , and Foote, A. (1988). Health care cost-containment through worksite wellness program. In C.H. Grimes (Ed.), EAP research: An annual of research & research issues (Vol. 2). Troy, MI: Performance Resource Press. Erfurt, J . C , Foote, A., and Heirich, M.A. (1989a). Worksite wellness programs: Incremental comparison of screening and referral alone, health education, followup counseling, and plant organization. Unpublished manuscript, University of Michigan, Ann Arbor, MI. Erfurt, J . C , Foote, A., and Heirich, M.A. (1989b). Preventing cardiovascular disease through worksite health promotion. (Three-year findings from rescreening data). Final report to UAW-General Motors and NHLBI on the University of Michigan/ General Motors/UAW Wellness Study. Ann Arbor, MI: Worker Health Program, Institute of Labor and Industrial Relations, University of Michigan. Erfurt, J . C , Foote, A., Heirich, M.A., and Gregg, W. (1989). Improving participation in worksite wellness programs: Comparing health education, a menu approach, and follow-up counseling. Unpublished manuscript, University of Michigan, Ann Arbor, MI.

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Foote, A., and Erfurt, J.C. (1977). Controlling hypertension: A cost-effective model. Preventive Medicine, 6, 319-343. Foote, A., and Erfurt, J.C (1982). Hypertension control in the work setting: The University of Michigan-Ford Motor Company demonstration program (NTIS Publication No. PB-83-113399). Springfield, VA: National Technical Information Service. Foote, A., and Erfurt, J.C. (1983). Hypertension control at the work site: Comparison of screening and referral alone, referral and follow-up, and on-site treatment. New England Journal of Medicine, 308, 809-813. Foote, A., and Erfurt, J.C (1984). Designing a successful hypertension control program. Business and Health, 1, 13-18. Foote, A., and Erfurt, J.C. (1988). EAP follow-up as a relapse prevention strategy (Final report to NIAAA, Grant R01-AA06567-03). Ann Arbor, MI: Worker Health Program, Institute of Labor and Industrial Relations, University of Michigan. Foote, A., Erfurt, J . C , and Heirich, M.A. (1989c). Interim report on the University of Michigan wellness program (a research study in progress 1988-1989). Ann Arbor, MI: Worker Health Program, Institute of Labor and Industrial Relations, University of Michigan. Foote, A., Erfurt, J . C , and Strauch, P.A. (1986, May 21). GM-UAW pilot structured aftercare program (Final report to UAW-General Motors EAP). Ann Arbor, MI: Worker Health Program, Institute of Labor and Industrial Relations, University of Michigan. Gorbachev, M. (1987). Perestroika: New thinking for our country and the world. New York: Harper and Row. Hypertension Detection and Follow-up Program Cooperative Group. (1979, December 7). Five-year findings of the hypertension detection and follow-up program: I. Reduction in mortality of persons with high blood pressure, including mild hypertension. Journal of the American Medical Association, 242 (23), 2562-2571. Hypertension Detection and Follow-up Program Cooperative Group. (1982). The effect of treatment on mortality in "mild" hypertension. New England Journal of Medicine, 307, 976-980. Logan, A.G., Milne, B.J., Achber, C , Campbell, W.P., and Haynes, R.B. (1979). Work-site treatment of hypertension by specially trained nurses: A controlled trial. Lancet, 1175-1178. Wilber, J.A., and Barrow, J.G. (1969). Reducing elevated blood pressure—Experience found in a community. Minnesota Medicine, 52, 1303-1305.

19 A SYSTEMATIC APPROACH TO THE EVALUATION OF EMPLOYEE ASSISTANCE PROGRAMS: A CONCEPTUAL ANALYSIS LINDA F. PATRICK

In the past several years, many criticisms have been leveled at employee assistance programs (EAPs) concerning the lack of sound evaluation research to establish the effectiveness of the programs. After thorough reviews of the literature, J.M. Jerrell and J.F. Rightmyer (1982) refer to the "paucity of rigorous evaluation attempts thus far" (p. 265); N.R. Kurtz, B. Googins, and W.C. Howard (1984) conclude: "In our review of the literature, we were unable to find any evaluation . . . that represented a reasonable approximation of the minimal research design" (p. 37). S.H. Klarreich, J.L. Francek, and C.E. Moore state: "Efforts to do research and evaluation on the overall effectiveness of EAPs . . . have not been scientifically rigorous and conclusive" (1985, 4). Many others (Battle, 1988; Cayer and Perry, 1988; Durkin, 1985; Roman, 1981a; Walsh, 1982; Washousky and Kruger, 1984) echo Googins' claim that "despite the heralded acclaim which EAPs have received over the past several years, little substantive research has yet to be conducted to verify the effectiveness of these programs" (1985, 222). Despite these criticisms, the support of existing EAPs seems very secure and new programs continue to be established. From fewer than 100 programs in the early 1970s, the number of programs has increased to an estimated 12,000 in 1986 (Roman and Blum, 1987). Not only are the numbers of programs increasing, the existing programs seem to enjoy enthusiastic support from all corners. Many authors (Balzer and Pargament, 1988; Dickman and Emener, 1982; Kurtz, Googins, and Howard, 1984; Roman, 1981a; Washousky and Kruger, 1984) have referred to testimonials from managers, labor leaders, and others directly involved in the conduct and support of their company's EAP, and all have expressed a high level of optimism concerning the success and effectiveness of the programs. D.C. Walsh summarizes these sentiments: "[Managers] seem sanguine,

298

Employee Assistance Programs

even enthusiastic, about their investments in these programs," but she adds: "but [they] lack empirical evidence to support their intuition" (1982, 508). This chapter addresses this somewhat perplexing situation by suggesting two paradigms or perspectives of evaluation and by considering the appropriateness of each perspective for the evaluation of EAPs. The above cited criticisms of EAP evaluation have their basis in the traditional, goal-attainment perspective of evaluation. This approach is used to assess whether program goals have been reached and whether the program caused the intended effects. Goal-attainment evaluation was used extensively to assess the social ameliorative programs that flourished in the 1970s. This type of evaluation may not be indicated, however, under conditions that are different from those related to the programs of the 1970s. Employee assistance programs share some similarity with these programs, but they are also different in some ways. Both are human service delivery programs, but EAPs generally function within, and are funded by, private industry. The voluntary nature and private funding of EAPs may be the key to understanding the "perplexing situation" presented above. Continued support for the programs may not hinge on scientifically demonstrated goal attainment, but may be related to other factors that make this approach to evaluation inappropriate. The following sections of this chapter explore the possibility of conducting methodologically sound evaluations of EAPs by demonstrating how characteristics of programs dictate what type of evaluation may be performed. Not only is the definition of evaluation refined into two perspectives, but each perspective is linked to aspects of programs. Generally speaking, the terms "evaluation" and "program evaluation" refer only to the goal-attainment perspective. Another perspective, the managerial, has an equally long history but has not received as much attention as a legitimate method for assessing programs. Employee assistance programs offer a unique opportunity to examine the interrelatedness of program characteristics and approach to evaluation. By extending the definition of evaluation to include the managerial approach, a different perspective on the evaluation of EAPs is gained. The first section of this chapter examines the characteristics of EAPs that have implications for evaluation. The second section contrasts the goal-attainment, or accountability, perspective with the managerial perspective. In the third section, the evaluability of EAPs is considered from each perspective. At the conclusion of the discussion, a model is developed that demonstrates evaluability from the managerial perspective. COMPONENTS AND CHARACTERISTICS OF EAPs In order to explore the relation between program aspects and evaluation perspective, the characteristics of the program to be evaluated should be clearly delineated. Both stated and unstated assumptions about program goals, intent, and purpose, as well as a consideration of the reasons for evaluation and the

A Systematic Approach to Evaluation

299

intended audience for the results, are necessary in order to assure the appropriate approach to program evaluation. Assumptions This discussion of the assumptions about EAPs will center around program assumptions as related to approach to evaluation. (Further enumeration and discussion of the underlying assumptions of EAPs can be found in Wrich, 1974; Roman and Blum, 1987; Shahandeh, 1985; and Shain and Groeneveld, 1980.) The underlying assumptions or philosophy of EAPs, in all their varieties, are based on an "individual model" approach to causation and remediation of problems (Shain and Groeneveld, 1980). The individual model, as contrasted with an environmental model, views the cause and the remediation of alcoholism and other problems as largely indigenous to the individual's psychological makeup. An environmental model attributes more of the causal and remedial factors to environmental and social, including organizational, origins. In their remediation efforts, EAPs do not focus on organizational or social changes, but rather on changes in the behavior of individuals within an organizational context. In this manner, EAPs are similar to the programs of the 1970s; that is, the focus of the program is on individual behavior change. There is an important difference, however, concerning the structure and process of EAPs and publicly funded social ameliorative programs. In order to function, an EAP is assumed to be integrated into the system of the work organization of which it is a part. Without at least minimal integration, the EAP would no longer be an EAP. An essential part of the purpose of an EAP is to be responsive to the needs of the organization and the employees of the organization. There has been some debate as to whom the EAP is responsible—the work organization or its clients, the employees (Briar and Vinet, 1985). It may be argued that the primary beneficiary of an EAP is the "troubled" employee; that is, the EAP offers to this person the opportunity for a healthier, happier lifestyle. However, these benefits are therapy or treatment goals and, as such, do not represent the complexities of the EAP situation (Blum, 1984). EAPs always, by definition, function within the context of work organizations, and program goals must therefore, in some way, be related to the work setting. Thus goals solely focused on the remediation of individual behavioral problems appear inadequate. When considering the assumptions about the nature of EAPs, it is useful to review what has been written about definition, components, and goals of the programs. An attempt is made to identify common characteristics and the major variations in the design of the programs. Definition and Common Elements Employee assistance programs have been defined as follows:

300

Employee Assistance Programs

a labor and management control system designed to earlier identify employees when their problems impair job performance and motivate them to receive assistance to resolve the problem (Wrich, 1974, 14) and a job-based program operating within a work organization for the purposes of identifying ''troubled employees," motivating them to resolve their troubles, and providing access to counseling or treatment for those employees who need these services. (Sonnenstuhl and Trice, 1986, 1) The globality of these definitions is made necessary by the many variations in structure and function of operational EAPs. There are, however, several structural components that are necessary for a program to be considered an EAP: 1. Designated staff who are competent in assessment, supervisory consultation, and education 2. Supervisory (and shop steward in unionized settings) training in methods of constructive confrontation and education concerning the policies and procedures of the EAP 3. Employee education concerning the EAP policies and procedures 4. Access to a continuum of treatment services including, in most cases, third-party payment for the services. In addition to these structural components, several other elements are considered necessary: (1) written policies and procedures, (2) support and cooperation from management and labor, (3) problem identification through job performance criteria, (4) assurance of confidentiality, and (5) temporary suspension of disciplinary actions while the employee receives EAP services (Roman and Blum, 1985; Shain and Groeneveld, 1980; Spicer, 1987; Walsh, 1982; Wrich, 1974). Variations in Design Many variations exist in the approach, location, and structure that incorporate these "essential elements." In attempts to refine further the parameters of EAPs, several authors have offered categories to describe the variations. D. Jones (1987) lists five "models" of EAPs that result from differing corporate goals: alcohol or other drug, broadbrush, wellness and health promotion, marketing strategy, and cost containment. J.C. Erfurt and A. Foote (1985) present a model of three systems of activity that occur within EAPs: case finding and confrontation; assessment, referral, and follow-up; and treatment. Variation in design is discussed within each of these three systems of activity. They suggest that there is no "discrete set of program designs, but rather a variety of decision points in developing a program" (1985, 56). Two primary factors determine the design of the program. Program objectives determine activities, functions, and staffing

A Systematic Approach to Evaluation

301

arrangements; and the size and structure of the parent organization determine the distribution of the functions within the organization and external organizations. Variation in approach, function, and location are listed by Walsh (1982). Approach varies from strictly alcoholism to broadbrush. Function varies from limited (consultation and outreach) to comprehensive (diagnostic and treatment). Location varies from inhouse to external contracts with consultants, consortia, and treatment centers. Goals Variations in program design are closely linked to variations in program goals. Theoretically, the design is determined by the goals. Typically, however, goals, per se, of EAPs are not directly addressed, but rather outcomes, impacts, and benefits are described. Kurtz, Googins, and Howard (1984) list four categories of success indicators: changes in drinking behavior, changes in level of work performance, estimates of cost reduction, and penetration rates. Jerrell and Rightmyer (1982) categorize outcome indicators into four clusters of variables: (1) accidents, sick leave, medical and surgical costs, and insurance premiums; (2) absenteeism, tardiness, and inefficiency on the job; (3) rehabilitation rates; and (4) job performance ratings, grievances, disciplinary actions, and labor arbitration incidences. Beneficiaries of EAPs are many: the employees, the employer, unions, families, dependents, and the community at large (McClellan, 1982; Roman and Blum, 1987). Implications for Evaluation Using the terminology of research, a traditional evaluation of a program is focused on independent variables and dependent variables. The independent variables are the components of the program that cause the desired outcomes or dependent variables. In order to be evaluated, a program must have specified independent variables and specified dependent variables. Recent publications (Albert, Smythe, and Brook, 1985; Feit and Holosko, 1988) have focused on the difficulties in specifying both the independent and the dependent variables for EAPs. The above discussion of definitions and the variability of design demonstrates the near impossibility of specifying independent variables that are applicable to all EAPs. Because they are integrated into the organizational structure and are designed to meet the needs of a particular organization, the programs do not comprise identical components (independent variables). M.D. Feit and M.J. Holosko identified four "generations" of programs that have emerged in EAP history. The first generation was focused solely on alcohol problems, and the second generation was a broadbrush approach that expanded the focus of service to a broad range of behavioral problems as they related to

302

Employee Assistance Programs

job performance. The third and fourth generations of programs are currently emerging. These programs "take on a more proactive and preventative focus, and address issues related to overall employee health, well-being, and life-style" (1988, 282). Case management services are offered which tailor the services to the individual employee. These trends highlight the difficulty in specifying not only the dependent but also the independent variables for EAPs. Instead of becoming more conceptually consolidated, the programs are becoming more diverse, thus making the job of the evaluator more difficult. In the following sections of this chapter, the links between program characteristics and evaluation approach are elaborated. Programmatic differences between EAPs and other programs are discussed in relation to the appropriate evaluation approach to each type of program. APPROACHES TO EVALUATION The definition of evaluation is elusive indeed. In a statement which prefaces many current attempts to define evaluation, E.A. Suchman is often quoted: Currently, the term "evaluation" . . . is poorly defined and often improperly used. For the most part, its meaning is taken for granted and very few attempts have been made, even by those most concerned, to formulate any conceptually rigorous definition or to analyze the main principles of its use. . . . More serious than this looseness of definition is the absence of any clear-cut understanding of the basic requirements of evaluative research. (1967, 27) Evaluation is undertaken for a variety of reasons and consequently a variety of methods is employed. It is useful to summarize these reasons and methods into three perspectives: (1) accountability, (2) managerial, and (3) addition to the body of social scientific knowledge (Rutman and Mowbray, 1983). The third perspective, addition to the body of scientific knowledge, is rarely used as a reason for evaluation totally independent of the other two perspectives. Rather, it is incorporated into the other perspectives in varying degrees. The first two perspectives, accountability and managerial, constitute the heart of evaluation. All evaluations incorporate parts of one or both of these perspectives. In the following sections are pieced-together descriptions of each perspective in an attempt to accentuate the differences between them. Some authors (Attkisson and Broskowski, 1978; Rutman, 1980) blur the distinction between the two perspectives and incorporate aspects of both into their suggestions for definition and approach to evaluation. We propose, however, that each perspective represents different assumptions about the nature of programs. For our discussion about the special case of EAP evaluation, the distinction is important. It will become apparent in the following discussion that each perspective incorporates certain assumptions about the object of evaluation. These assump-

A Systematic Approach to Evaluation

303

tions form a "theoretical overlay" for the way in which we view programs and organizations and determine the type of model of evaluation used to assess them. The following discussion of the accountability perspective and the managerial perspective will therefore focus on these assumptions and will demonstrate the interdependence of one's assumptions regarding program functioning and the subsequent approach to evaluation. It could be argued, in fact, that each perspective is as descriptive of programs as it is of evaluations.

Accountability The accountability perspective (also referred to as outcome, summative, or goal-attainment evaluation) is closely tied to the social ameliorative programs that flourished under public auspices in the 1960s and 1970s. It was during this time period that publicly sponsored programs turned from the former pattern of distributive and maintenance programs, which were not focused on individual change, to programs that "took on a new orientation and the solution to the economic, social, and educational plight of the disadvantaged came to be viewed as requiring more direct attempts to change the personal qualities of the individuals" (Airasian, 1983, 165). The programs of the War on Poverty and the Great Society emphasized the change in the performance of people who received services rather than the former focus of concern with access to maintenance or distributive programs. As these programs became operational, it became increasingly evident that some means of assessment was necessary. The public, as well as sponsoring agencies, wanted some assurance that individuals were changing as a result of the programs. The methodologies of the accountability perspective of evaluation were used in attempts to provide the justification that was necessary for the social action programs to compete for and obtain continued funding from public monies. Several factors common to almost all of these programs helped to define the type of evaluation that was performed. The programs were generally funded by public monies; some, if not most, were considered demonstration projects; each targeted a specific problem area (e.g., teenage pregnancy) that was measurable by specific behavioral changes by targeted individuals; and each program was hypothesis based (e.g., sex education will decrease incidence of teenage pregnancy). Evaluators were charged with establishing whether the program goals had been reached (i.e., did the desired behavior change occur) and whether the program had caused the behavior changes. These charges dictated one of the essential characteristics of the accountability perspective—the use of scientific methodology. Reliability and validity of measurement and control of factors other than the hypothesized change agent were necessary. E.A. Suchman (1967) and C.H. Weiss (1972) offer elaborations of these methods. The characteristics and assumptions of the accountability perspective of evaluation can be summarized as follows:

304

Employee Assistance Programs

1. It is assumed that the program targets a relatively specific behavioral change as its goal (Attkisson and Broskowski, 1978). The unit of analysis is the individual. 2. It is assumed that the success or failure of the program is determined by whether or not the program's goals were accomplished. A corollary to this assumption is that the purpose of the program is to accomplish the stated goals. 3. It is assumed that the program implementation and process as well as its goals remain stable (cf. Weiss, 1972). This is necessary in order to maintain the established design and methodology of the study as well as to allow comparison between programs implemented in different sites. 4. The programs are hypothesis based (Babbie, 1986; Suchman, 1967). 5. Relations between variables are assumed to be linear (e.g., sex education and afterschool group meetings will increase self-esteem, which will result in a decrease in the incidence of pregnancy; a-b-c). 6. The design of the evaluation is determined by scientific methodology (Rutman and Mowbray, 1983; Suchman, 1967). 7. The ultimate goal of the evaluation is to establish cause-and-effect relationships through the use of quantitative scientific methods. 8. The audience is external as well as internal to the program. Managerial Whereas the ultimate purpose of evaluation from an accountability perspective is to assess overall quality and impact, the aim of evaluation from a managerial perspective is to improve the functioning of an ongoing program. Evaluation from this perspective is also referred to as formative, process, or systems evaluation. The development of the managerial perspective can be traced to two sources: (1) the problems experienced by evaluators using the accountability perspective and (2) the field of organizational analysis. The primary failings of the accountability approach are basically twofold: decision-makers rarely paid much attention to the results, and the evaluations rarely demonstrated significant behavior change attributable directly to the program's interventions (Weiss, 1972). Suggested reasons for the lack of utilization are many: (1) organizations are resistant to change (Weiss, 1972; Roman and Blum, 1985; Rutman, 1980); (2) the results may suggest changes that are unacceptable or are counter to prevailing values (Weiss, 1972); (3) the language of the evaluator may not be comprehensible to the program administrator (Roman and Blum, 1985); (4) the professed or stated goals may not be the actual or operational goals; therefore, assessment of the professed goals may not have meaning to the program administrator (Schulberg and Baker, 1968; Scott, 1987). Reasons suggested for the lack of significant results are poor management, failure to consider implementation factors (Corwin and Louis, 1982), lack of utilization of relevant knowledge (Weiss, 1972), focus on a single problem behavior rather than on the individual as a whole (Attkisson and Broskowski, 1978), and methodological difficulties such as identifying and

A Systematic Approach to Evaluation

305

controlling for the influence of factors other than the prescribed intervention (Suchman, 1967). Another influence in the development of the managerial perspective possibly came from the field of organizational analysis. This field of study forms the basis for academic training for managers and therefore often forms the managers' "perspective" of organizations and programs. Since lack of utilization of findings from the accountability perspective has been a major problem, it makes sense to gear evaluations to a perspective that can be useful and meaningful to decisionmakers in work organizations. The theoretical underpinnings of organizational analysis is systems theory. Organizations are viewed as systems operating in interaction with their environments. Subsystems, or components, form the system, and each subsystem has inputs and outputs that connect it to other parts of the system. The "open systems" approach (Scott, 1987) to organizational analysis incorporates the realities of change, uncertainty and complexity that are inevitable in organizations. The ultimate purpose of organizational systems is viewed to be survival (Thompson, 1967), and the existence of an organization does not depend solely, or most importantly, on the accomplishment of stated goals. The continued existence of the organization is felt to be controlled less by the organization but is ultimately responsive to political concerns and the realities of social desirability and economic demands. Managers are generally action oriented and want information that is immediately applicable to program or organizational improvement. They are also concerned about attaining the goals and desired outcomes, but their emphasis is on improving the functioning of the organization to achieve maximum effectiveness. Survival of the organization is not viewed to be dependent on the ultimate attainment of the stated goals (for a discussion of the complexity of goal establishment and assessment see Scott, 1987). In fact, within the field of organizational analysis, the assessment of goal attainment is thought to be possible only under certain, narrowly defined conditions such as those that exist in assembly-line production (Scott, 1987; Thompson, 1967). Generally speaking, in organizations that involve services to people, there are too many uncontrollable factors that affect the ultimate goals of the organization. The results of assessment of goal attainment in these situations can be misleading. For example, the ultimate goal of a community hospital could be community health, but the hospital is not considered a failure if there is a flu epidemic. Evaluation from a managerial perspective addresses, at least partially, the problems of the accountability perspective and offers relevant and understandable information to managers concerning the functioning of the program. Questions addressed by this perspective could be: Is the program being implemented according to plan? What factors are impeding implementation? Are the objectives being reached? What are the unintended effects of the program? How does current functioning affect intended outcomes? The methodology associated with this perspective is not as closely linked to

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scientific principles of research design as is the case with the accountability approach. Since attribution to specific causes for effects or outcomes is not the purpose of this perspective, the methodology is varied and specific to the requirements of the study. Qualitative methods are frequently used, especially in the initial stages, to identify unintended effects or to identify actual implementation. For example, for an evaluation of the functioning of a mental hospital, the following methods of data collection were used: field observations, interviews with staff, questionnaires, and institutional records review (Baker and Schulberg, 1973). The unit of analysis is the program or the organization as a system. This is contrasted with the accountability perspective which focuses on individual behavior change as the unit of interest. Because the conceptualization of a program as a system for evaluation is a highly complex endeavor, several authors (Borich and Jemelka, 1987; Rutman and Mowbray, 1983) have recommended the construction of a graphic model of the program to identify and clarify "the program's structure and underlying logic" (Rutman and Mowbray, 1983, 16). The model is based on systems concepts of inputs, transactions, and outputs, and it identifies the essential program components or structures and the linkages between and among the components and the outputs, objectives, and effects. The characteristics and assumptions of the managerial perspective of program evaluation can be summarized as follows: 1. The unit of analysis is the program as a system. 2. It is assumed that the ultimate objective of a program is continued existence. The program has little control over political, social, or economic influences, but it can maximize efficiency by monitoring program implementation and by making changes where necessary to increase efficiency. 3. It is assumed that the program is a system and operates in interaction with other systems in its environment. By implication, the program is fluid, not static. 4. Relations between variables can be linear or reciprocal. Complex relations between multiple variables can be demonstrated. 5. The methodology is dependent on the needs of the program and may be qualitative, quantitative, or a combination of both (see Borich and Jemelka, 1987, and Rutman and Mowbray, 1983, for a discussion of methodologies). 6. The audience is primarily internal. The evaluation is designed in conjunction with management to meet their information needs. EVALUABILITY OF EAPs Published Evaluation Studies Before we return to the initial question about the possibility of conducting sound evaluations of EAPs, a review of criticisms of published evaluations is in order. It is beyond the scope of this chapter to enumerate the many evaluation

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studies of EAPs that have been published to date. (For reviews see Jerrell and Rightmyer, 1982; Kurtz, Googins, and Howard, 1984.) These authors and others (Battle, 1988; Durkin, 1985; DuPont and Basen, 1980; Schlenger and Hayward, 1976; Walsh, 1982) have pointed out the multitude of flaws in this body of literature. The problem most frequently cited is the lack of methodology that permits generalization to other programs (external validity) and attributions to causal factors (internal validity). The lack of control and comparison groups and the dissimilarity of definition and measurement of variables are the primary validity problems. An infrequently mentioned concern is the focus on outcome or impact measures (Korr and Ruez, 1986). Most of the published evaluation studies of EAPs are concerned primarily with demonstrating outcomes or impacts derived from employees who have received services from EAPs. T.C. Blum (1984) pointed out that concentration on treatment outcomes may underestimate the impact of EAPs. Other factors such as impact of prevention, impact on work group morale, and motivation and job satisfaction generally are ignored. Another reference to the emphasis on outcome measures is the work of H.M. Trice and associates (Beyer and Trice, 1978; Trice and Beyer, 1977; Trice, Beyer, and Hunt, 1978) concerning the implementation of the federal alcoholism program policy. J. Beyer and H. Trice (1978) pointed out that information on outcomes "need[s] to be interpreted in the light of information about the extent and effectiveness of the implementation process." W.E. Schlenger and B.J. Hayward (1976) add that studies linking program components to outcomes are needed. More recently, E. Teram (1988) has emphasized the need for documentation of the implementation process. This focus on outcome and impact assessment may reflect a "rush to evaluation" that better serves concerns of those marketing EAP services as external contractors than it does program improvement or advancement of knowledge. It may be that the central weakness of EAP evaluation to date is not the specific methodological issues, but rather the approach to evaluation itself. If we consider the evaluation literature, a more systematic approach is possible—an approach that can lead to useful and sound assessment of program effectiveness. Evaluability Assessment The first step in a systematic approach is to consider aspects of the program and its readiness for evaluation. Certain factors have been identified that are considered necessary prerequisites for an evaluation of effectiveness (Rutman and Mowbray, 1983). These are the conditions for evaluation from an accountability perspective that allow an assessment of program goals or outcomes. The criteria, enumerated by Rutman and Mowbray, are well-defined programs that can be implemented in a prescribed manner, clearly specified goals and effects, and plausible causal linkages. Weil-Defined Programs. These conditions are necessary in order to know what,

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if anything, about the program produced the effects. In order for EAPs to meet this criterion, much more uniformity in program components and implementation process would be necessary. Given the variety of types of programs and the relative lack of knowledge of implementation, EAPs clearly do not meet this criterion at this point in time. Clearly Specified Goals and Effects. The primary reason for this criterion is to ensure the development of appropriate measure for the goals and effects. If the goals are vague or unspecified, then measurement of them is not possible. This criterion may or may not be met by EAPs. There are clearly many lists of measurable impacts or outcomes, but the difficulty is to determine relevant, measurable variables that are identified as goals of the programs. This is an area in which EAPs do not strictly "fit" the assumptions of the accountability perspective. EAPs, as discussed earlier, do have individual behavior change goals, but they also have other goals related to the parent organization. These goals are not always clearly specified and measurable. Plausible Causal Linkages. This criterion assesses whether the program has a chance of meeting its goals. By implication, the goals and effects must not only be clearly specified, they must also be plausible. This is another area in which EAPs do not fit the assumptions of the accountability perspective. Strictly speaking, the EAP does not cause the outcomes and impacts that have been attributed to it. The EAP is rather a facilitator of events that cause the effects. EAP staff members facilitate recognition of problems, they facilitate treatment arrangements, and they facilitate the reintegration of the employee after treatment. EAPs, however, do not directly cause individual behavior change (except perhaps in those atypical situations where a continuum of treatment is offered within the EAP). From these criteria, it is evident that given the current state of EAPs, evaluations from the accountability perspective are premature at best. Some theorists (Rutman and Mowbray, 1983; Suchman, 1967; Weiss, 1972) view evaluation with strict managerial perspective assessments on one end of a continuum and strict accountability perspective assessments on the other end of the continuum. They view managerial evaluations as the precursors of accountability evaluations. Other theorists (Etzioni, 1960; Baker and Schulberg, 1973; Borich and Jemelka, 1987; Yuchtman and Seashore, 1967) view evaluations from the managerial perspective not only as ends unto themselves, but as the preferred approach to the evaluation of organizations. Regardless of one's theoretical position on this issue, evaluations from a managerial perspective are indicated for EAPs for two reasons. From an organizational analysis perspective, this may be all that is necessary. Second, from an accountability perspective, it is a necessary first step. A SYSTEMATIC APPROACH The first step in evaluation from a managerial perspective is to develop a graphic model of the program (Borich and Jemelka, 1987; Rutman and Mowbray,

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1983; Weiss, 1972). The process of development of this model clarifies the position of the program in relation to the three criteria for accountability assessment. It also results in a model that represents systems interactions that is considered basic to assessment from a managerial approach. L. Rutman and G. Mowbray suggest several steps in the development of this model. The first step is to construct a "documents model." This involves examination of relevant documents about the program to determine formal commitments, purposes of the program, its components and outputs, and the relations between its components and outputs. From this information, they suggest listing "all program components, outputs, objectives, and effects" (1983, 50). From this list, a documents model is constructed that first identifies program components. Program components are the essential parts of the program that can be linked to measurable outputs. Support services are seen as essential to program operation, but they are not directly responsible for program outputs and so are therefore not included in the model. After the program components are identified, measurable outputs of each component are identified. Examples of output are the number of individuals served, the number of sessions held, the number of referrals, and so on. From these outputs, it is possible to list several levels of objectives or effects ranging from immediate to ultimate or long term. At this point in the process, emphasis is placed on identification of components, outputs, and effects, and the linkages among them. The linkages are considered very important in establishing the structure and underlying logic of the program. Before the model is final, the authors suggest that interviews be conducted with the program manager and key staff and that changes be made to the model if necessary to incorporate their understanding of the program. The resulting model then forms the basis for evaluation that will provide information that is useful and relevant to decision-makers. The model presented in Figure 19-1 depicts an interpretation of an EAP based on earlier stated definitions, essential components, and goals and effects. This model represents the results of step one, developing a documents model of a theoretical EAP. In the top section of the model are the components considered necessary for an EAP. Access to treatment is independent of other components. Supervisory training and employee education are components, but are also outputs of the EAP staff. Constructive confrontation is linked by a broken line as an output of supervisory training. It may or may not be a direct output of supervisory training by the EAP staff. Outputs of the components are listed in the next section of the model. These outputs are relatively simple indicators of the services performed by each of the components as related to the ultimate goals of the program. Broken lines connect supervisory training and employee education to the number of employees assessed, which is a direct output of the EAP staff. These lines indicate that these two components, either through their outputs or immediate effects, may affect the number of employees assessed.

Figure 19-1 Documents Model of an EAP

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It should be emphasized that, from a managerial perspective of evaluation, the variables listed at the output level are very important indicators of the implementation and operation of the program. This information can be collected easily and accessed. In fact, many EAPs already have this information about their programs. Data from a study of EAPs (Roman and Blum, 1987) showed that 60 percent of the programs surveyed had a data base containing at least some output information. In contrast, only 6 percent reported contracting for formal evaluations that can be regarded as conducted from the accountability perspective. The immediate effects and goals are listed next in the model. Each is a potentially measurable effect of each of the outputs listed above. The next level of effects are the intermediate effects. This is the area that has received perhaps the most attention by evaluators. This model depicts how this area is (theoretically) linked to EAP components, outputs, and other effects and goals. The broken line from the immediate effect, "employee is aware that performance is unsatisfactory," indicates that an employee may bypass the EAP and seek and receive services independently. Unbroken lines connect the effect, "employees receive appropriate services," back to the EAP staff component through two avenues: (1) assessment and referral (direct contact) and (2) indirect contact through the EAP staff's contact with community services in order to evaluate services and to maintain contact with the employee while she or he participates in the service. Another intermediate effect of the EAP staff's contact with community services is that effective service resources are maintained and the staff are able to participate in after-service planning and to participate in the reintegration of the employee into the work setting as a fully participating member of the work force. A direct effect of the employee's receiving appropriate services is his or her reintegration back into the work setting at a satisfactory level of performance. This results directly in the ultimate goals of improvement of job performance indicators and decreases in health benefits payments. A broken line connects employee awareness of unsatisfactory job performance to the ultimate goal of improved job performance to indicate the possibility of this linkage. The ultimate goals in this model are organization-wide indicators and are not limited to those employees who participated in the EAP. At this point, measurement of these variables is fraught with problems, and it is unlikely that these effects can be demonstrated. Not only are there measurement problems, but there are also many other factors that could influence these outcomes. EAPs are only one of these factors. Even though they may not be demonstrable at this point, these goals are important in describing the intended long-term organizational effects of the EAP. This model is presented as an example of the possible linkages between the EAP components and their intended effects. It identifies the underlying logic of a program and identifies many measurable variables that could be used to evaluate all or any part of the system. It not only graphically depicts the individual

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employee (treatment) aspects of the program, but also shows integration into and dependence upon the parent organization in its components and its effects. This documents model represents a possible first step of an evaluation from a managerial perspective that can provide useful additions to the EAP evaluation literature. Very little is currently known about variations in structure and processes and the effects these have on different levels of goals. Evaluation from this perspective should also prove to be immediately useful in providing feedback to program administrators about the strengths and weaknesses of their program operations.

NOTE The author acknowledges postdoctoral fellowship support at the University of Georgia from Training Grant T32-AA-07473 from the National Institute on Alcohol Abuse and Alcoholism.

REFERENCES Airasian, P.W. (1983). Social experimentation. In G.F. Madaus, M.S. Scriven, and D.L. Stufflebeam (Eds.), Evaluation models: Viewpoints on educational and human services evaluation (pp. 163-175). Boston: Kluwer-Nijhoff Publishing. Albert, W.C., Smythe, P.C., and Brook, R.C. (1985). Promises to keep: An evaluator's perspective on employee assistance programs. Evaluation and Program Planning, 8, 175-182. Attkisson, C.C., and Broskowski, A. (1978). Evaluation and the emerging human service concept. In C.C. Attkisson, W.A. Hargreaves, M.J. Horowitz, and J.E. Sorensen (Eds), Evaluation of human service programs (pp. 3-26). New York: Academic Press. Babbie, E. (1986). The practice of social research. Belmont, CA: Wadsworth Publishing Company. Baker, F., and Schulberg, H.C. (1973). A systems model for evaluating the changing mental hospital. In F. Baker (Ed.), Organizational systems: General approaches to complex organizations (pp. 476-488). Homewood, IL: R.D. Irwin. Balzer, W.K., and Pargament, K.I. (1988, January/February). The key to designing a successful EAP. EAP Digest, 55-59. Battle, S.F. (1988). Issues to consider in planning employee assistance program evaluations. Employee Assistance Quarterly, 3 (3/4), 79-93. Beyer, J.M., and Trice, H.M. (1978). Implementing change: Alcoholism policies in work organizations. New York: The Free Press. Blum, T.C. (1984, October). Underestimating the impact of employee assistance programs through the use of classical evaluation designs. Paper presented at the annual meeting of ALMACA, Denver, CO. Borich, G.D., and Jemelka, R.P. (1987). Programs and systems: An evaluation perspective. New York: Academic Press. Briar, K.H., and Vinet, M. (1985). Ethical questions concerning an EAP: Who is the client? (Company or individual?). In S.H. Klarreich, J.L. Francek, and C.E.

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Moore (Eds.), The human resources management handbook: Principles and practice of employee assistance programs (pp. 342-359). New York: Praeger. Cayer, N.J., and Perry, R.W. (1988). A framework for evaluating employee assistance programs. Employee Assistance Quarterly, 3 (3/4), 151-168. Chelimsky, E. (1978, Summer). Differing perspectives of evaluation. New Directions for Program Evaluation, 1-18. Corwin, R.G., and Louis, K.S. (1982). Organizational barriers to the utilization of research. Administrative Science Quarterly, 27, 623-640. Dickman, F., and Emener, W.G. (1982, August). Employee assistance programs: Basic concepts, attributes and an evaluation. Personnel Administrator, 55-62. DuPont, R.L., and Basen, M.M. (1980). Control of alcohol and drug abuse in industry— A literature review. Public Health Reports, 95 (2), 137-148. Durkin, W.G. (1985). Evaluation of EAP programming. In S.H. Klarreich, J.L. Francek, and C.E. Moore (Eds.), The human resources management handbook (pp. 243259). New York: Praeger. Erfurt, J . C , and Foote, A. (1985). Variations in EAP design. In S.H. Klarreich, J.L. Francek, and C.E. Moore (Eds.), The human resources management handbook (pp. 45-57). New York: Praeger. Etzioni, A. (1960). Two approaches to organizational analysis: A critique and a suggestion. American Science Quarterly, 5, 257-278. Feit, M.D., and Holosko, M.J. (Eds.). (1988). Evaluation of employee assistance programs [Special issue]. Employee Assistance Quarterly, 3 (3/4). Googins, B. (1985). Can change be documented? Measuring the impact of EAPs. In S.H. Klarreich, J.L. Francek and C.E. Moore (Eds.), The human resources management handbook (pp. 222-231). New York: Praeger. Jerrell, J.M., and Rightmyer, J.F. (1982). Evaluating employee assistance programs. Evaluation and Program Planning, 5, 255-267. Jones, D. (1987). Evaluation. In J. Spicer (Ed.), The EAP solution: Current trends and future issues (pp. 99-130). Center City, MN: Hazelden. Klarreich, S.H., Francek, J.L., and Moore, C.E. (Eds.). (1985). The human resources management handbook. New York: Praeger. Korr, W.S., and Ruez, J.F. (1986). How employee assistance programs determine service utilization: A survey and recommendations. Evaluation and Program Planning, 9, 367-377. Kurtz, N.R., Googins, B., and Howard, W.C., (1984). Measuring the success of occupational alcoholism programs. Journal of Studies on Alcohol, 45 (1), 33-45. Madaus, G.F., Scrivin, M.S., and Stufflebeam, D.L. (1983). Program evaluation: A historical overview. In G.F. Madaus, M.S. Scriven, and D.L. Stufflebeam (Eds.), Evaluation models: Viewpoints on educational and human services evaluation (pp. 3-22). Boston: Kluwer-Nijhoff Publishing. McClellan, K. (1982). An overview of occupational alcoholism issues for the 80s. Journal of Drug Education, 12 (1), 1-27. Roman, P.M. (1981a). Evaluation of employee alcoholism programs. Labor-Management Journal on Alcoholism, 11, 1-12. Roman, P.M. (1981b). From employee alcoholism to employee assistance. Journal of Studies on Alcohol, 42 (3), 244-269. Roman, P.M. (1988). Growth and transformation in workplace alcoholism programming.

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In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 131-158). New York: Plenum Press. Roman. P.M., and Blum, T.C. (1985). The core technology of employee assistance programs. Almacan, 15 (3), 8-12. Roman, P.M., and Blum, T.C. (1987). The relation of employee assistance programs to corporate social responsibility attitudes. In L. Preston and W. Frederick (Eds.), Research in corporate social performance and policy (Vol. 9, pp. 213-235). Greenwich, CT: JAI Press. Rutman, L. (1980). Planning useful evaluations: Evaluability assessment. Beverly Hills, CA: Sage Publications. Rutman, L., and Mowbray, G. (1983). Understanding program evaluation. Beverly Hills, CA: Sage Publications. Schlenger, W.E., and Hayward, B.J. (1976, Spring). Occupational programming: Problems in research and evaluation. Alcohol Health and Research World, 18-22. Schulberg, H.C., and Baker, F. (1968). Program evaluation and the implementation of research findings. American Journal of Public Health, 58, 1249-1255. Scott, W.R. (1987). Organizations: Rational, natural, and open systems (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall, Inc. Shahandeh, B. (1985). Drug and alcohol abuse in the workplace: Consequences and countermeasures. International Labour Review, 124 (2), 207-223. Shain, M., and Groeneveld, J. (1980). Employee assistance programs: Philosophy, theory, and practice. Lexington, MA: D.C. Heath and Company. Sonnenstuhl, W.J., and Trice, H.M. (1986). Strategies for employee assistance programs: The crucial balance. Ithaca, NY: ILR Press. Spicer, J. (1987). EAP program models and philosophies. In J. Spicer (Ed.), The EAP solution: Current trends andfuture issues (pp. 3-17). Center City, MN: Hazelden. Suchman, E.A. (1967). Evaluation research. New York: Russell Sage Foundation. Teram, E. (1988). Formative evaluation of EAPs by studying role perceptions and organizational cultures. Employee Assistance Quarterly, 3 (3/4), 119-128. Thompson, J.D. (1967). Organizations in action. New York: McGraw-Hill. Trice, H.M., and Beyer, J.M. (1977). Differential use of alcoholism policy in federal organizations by skill level of employees. In C. Schramm (Ed.), Alcoholism and its treatment in industry (pp. 44-69). Baltimore, MD: Johns Hopkins University Press. Trice, H.M., Beyer, J.M., and Hunt, R.E. (1978). Evaluating implementation of a job based alcoholism policy. Journal of Studies on Alcohol, 39, 448-465. Walsh, D.C. (1982). Employee assistance programs. Milbank Memorial Fund Quarterly/ Health and Society, 60 (3), 492-517. Washousky, R . C , and Kruger, R.M. (1984, March/April). Evaluating employee assistance through supervisor follow-up. EAP Digest, 32-45. Weiss, C.H. (1972). Evaluation research. Englewood Cliffs, NJ: Prentice-Hall. Wrich, J.T. (1974). The employee assistance program. Center City, MN: Hazelden. Yuchtman, E., and Seashore, S.E. (1967). A system resource approach to organizational effectiveness. American Sociological Review, 32, 891-903.

20 ALCOHOLISM TREATMENT PROVIDERS AND THE WORKPLACE LISA K. BLOCK

National concerns about escalating costs and the management of health care have led researchers to explore the nature of specific health care delivery systems. One relatively new health care system that currently is generating research interest is treatment of alcoholism and drug addiction. Private alcohol and drug programs have rapidly multiplied over the last decade and are now widely available across the country. Surveys conducted jointly by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) show a 76-percent increase in the number of privately owned treatment centers between 1979 and 1984, with the majority of change resulting from a sharp increase in the number of private for-profit centers (Reed and Sanchez, 1986). This chapter explores the emergence of private sector treatment for alcoholism, the existence of workplace linkages to this treatment system, and, more extensively, the nature of these linkages. The emergence of private sector treatment for chemical dependency has its primary roots in the recognition and promotion of the view that alcoholism is a disease rather than a criminal or moral problem (Roman, 1988a). Its diffusion has been facilitated by promotion of the belief that alcoholism impacts all social classes equally, a phenomenon labeled the new epidemiology (Roman and Blum, 1987). The medicalization of alcoholism and the new epidemiology were central in the establishment of the NIAAA in 1970, the efforts of which have been indirectly responsible for mainstreaming alcohol treatment into the health care system. NIAAA focused on three elements to help accomplish mainstreaming. First, the new epidemiology had to be cultivated so that alcoholism was no longer seen as moral decay, found primarily among skid row public inebriates, but as a mainstream health problem. Second, to introduce alcohol treatment into the

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health care system, health care insurance had to be broadened so that this category of treatment would be covered. Third was the necessity of establishing a source of clients to use the alcohol treatment services. The most appropriate source of potential patients, in terms of both the magnitude of numbers and the greater likelihood of clients having health insurance coverage, was the American work force. Thus, the field of employee assistance programming (EAP) was initiated as a mechanism to identify employees with alcohol problems and to refer them to appropriate treatment in the community (Roman and Blum, 1987). It was the success of these workplace programs that partially led to the emergence and survival of the private treatment system (Roman, 1988b). The expansion of health insurance coverage to include alcoholism was also vital to the emergence of private sector treatment (Weisner and Room, 1984). The private treatment system has evolved rapidly and has become differentiated, offering a multitude of services including inpatient and outpatient treatment for adolescents and adults, education and intervention programs for the community, and sometimes EAP services for local companies. Regardless of the services offered, the private treatment center is concerned with maintaining a certain level of input resources, namely patients. Since, as private agencies, these centers are financially dependent upon reimbursement for the services provided, revenues decrease when the number of clients served decreases. Therefore, it is to be expected that treatment programs aggressively pursue and develop contacts with those who may be potential sources of patients. This pursuit of patients is in part necessary since the growth in the private alcoholism treatment system has not been totally in response to the need for alcoholism treatment, but has also become an important means to fill underutilized beds in general and psychiatric hospital settings (Weisner and Room, 1984). Since the majority of Americans are employed in some manner and increasingly have some form of health insurance, the workplace is a viable source of potential clients. One promising source of patients for treatment centers is the EAP within the workplace. Collectively, EAPs handle many cases involving alcohol and drug abuse. The relationship between particular EAPs and community treatment providers varies, yet it is evident that some contact must exist between the two types of organizations. In discussing the core technology of EAPs, P. Roman and T. Blum (1988) identify strategies common to most EAPs involving the creation of micro- and macrolinkages between EAPs and local treatment providers. Thus, an essential element of an EAP's operation is the formation of referral relationships with various treatment services in the community. On the other hand, treatment centers also must have some link with EAPs, not only to pursue a supply of patients, but also to handle their professional commitments to maximizing recovery, which may include back-to-work issues of patients and the reentry into the workplace. Because this interorganizational relationship is readily visible, EAPs are part of the treatment organizations' environment and vice versa. According to the open-system theory, organizations function within a context

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that includes their environment (Hall, 1977; Katz and Kahn, 1966). The external environment provides resources and feedback to organizations and utilizes and absorbs the outputs from organizations. Based on this assumption that organizations operate as open rather than closed systems, J. Pfeffer and G.R. Salancik (1978) propose a resource-dependence model of organizational functioning. They postulate that an organization is externally controlled or dependent upon its environmental resources for survival. This organizational/environmental relationship can readily be seen when examining private alcoholism treatment centers. These organizations must have effective transactions with their environments in order to obtain the resources (consumers) necessary for their financial stability. Interorganizational relationships also can be viewed in terms of exchange theory. S. Levine and P.E. White propose exchange theory as a conceptual framework for examining the interactions between organizations. They define exchange as "any voluntary activity between two organizations which has consequences, actual or anticipated, for the realization of their respective goals or objectives" (1974, 548). Furthermore, the activity process may be unidirectional, but the consequences of the action must be beneficial to both organizations. In the present case, the action is the unidirectional referral of patients; however, the consequences of this activity help both treatment centers and EAPs achieve goals. In other words, the referrals from EAPs help the treatment centers realize their patient census goals and the treatment that is produced assists EAPs in their goal of enhancing the recovery and return to work of employees with alcohol problems. It is important to study resource-dependent organizations or organizations involved in resource exchange in order to understand how these interrelations emerge. Such research also can elucidate how interorganizational relationships impact on the intraorganizational structure and process. The focus here is upon the nature of the interorganizational relationship between private alcoholism and drug-treatment programs and the workplace. The means by which treatment providers establish and maintain this alliance are discussed. Some insights are offered regarding the consequences of this relationship on the intraorganizational structure and process within treatment centers. The basis for the discussion is an empirical study conducted in a sample of private treatment centers. The details of this study are presented first, followed by findings regarding EAP and industry linkage to treatment. TREATMENT CENTER STUDY Selection of Centers A sample of 125 privately owned inpatient alcoholism treatment centers was selected for data collection in 1988 and 1989. Both hospital-based and freestanding centers were included. Not-for-profit as well as for-profit organizations were involved in the project. Public centers were excluded from the sample. Such

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centers have traditionally treated indigent patients and have had less concern with patient census. Although public centers find it desirable to have some paying patients to supplement funding, they typically do not aggressively market their services to the workplace. Sample states were chosen in such a way that the overall sample would reflect a composite of treatment programs across the country. Georgia, Florida, California, New York, and Minnesota were sampled. The southeast was represented somewhat more heavily than the other regions because of the proximity of this region's treatment centers to the project's home base at the University of Georgia. Several sources were used to identify the population of alcoholism treatment centers in each state; directories published by state agencies and by the National Association of Alcohol Treatment Programs (NAATP) and city telephone directories were all utilized to locate and accumulate each state's treatment center population. In Georgia, the entire population of private adult treatment centers was used in the study. Sampling from the other four states was conducted randomly within geographic regions of those states. For example, the centers in California were clustered around San Francisco, Sacramento, Los Angeles, and San Diego. Therefore, a sample was randomly selected for each of these locales as well as for the middle region between San Francisco and Los Angeles. The final sample included approximately 45 percent of the private alcoholism treatment centers in New York, Minnesota, and Florida and 25 percent of the centers in California. Participation in this research project required a considerable allotment of time from the staff of each selected center. Yet, following sample selection and invitations to participate in the study, the refusal rate was less than 10 percent. Some of these refusals were, in actuality, suggested postponements until some future date when program personnel would have more time to participate. Data were collected primarily through on-site interviews. Three interviews were designed for specific personnel in each treatment center: director or administrator interview, clinical supervisor or head counselor interview, and marketing or community relations personnel interview. Personnel in the third category were not present in all centers; in these instances marketing information was collected from the center directors. Administrator interviews included questions on the history and background of the center; physical and organizational structure; personnel, cost, and financial elements; referral patterns; the center's relationship to business and industry; and evaluation of the center's goal attainment. In addition, opinions regarding trends in alcoholism treatment were obtained. The clinical interview comprised items encompassing all aspects of client treatment including questions about intake, assessment, detoxification, rehabilitation, and aftercare. Also included were inquiries about treatment staff and patient demographics. About 50 percent of the programs had some form of outpatient services in addition to residential treatment. If a center offered out-

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patient services, further data were collected from the appropriate person (e.g., the outpatient supervisor) about their program. The third type of interview was conducted with a marketing or community relations person. About 50 percent of the centers had such a position. The main thrust of this interview was directed at the strategies used to generate continuous patient flow into the program. In particular, inquiries were made about the center's relationship to EAPs and industry. General Findings Of the 125 centers in the sample, 34 percent were freestanding units and 66 percent were hospital-based programs. With regard to their financial orientation, 63 percent were for-profit centers. The cost for treatment in these centers ranged from $1,000 to $25,000 for a 28-day stay, with a mean cost per day of $347. The data reveal that for-profit centers generally are more costly. Aside from cost, the treatment services provided by the centers in the sample varied in quantity and magnitude. Many centers offered numerous treatment alternatives such as inpatient services, day outpatient services, evening outpatient services, and sometimes a combination of the three. The length of the inpatient programs was fairly uniform across centers, but outpatient program length was diverse. Besides differing on the number of alternatives and the length of programs, centers were also found to differ with respect to what services they provided for special populations of patients. For example, some centers had separate tracks for treating codependents, cocaine addicts, homosexuals, women, and chronic relapsers. Although it appears on the surface that treatment centers differ widely from one another, the actual treatment modalities used are very much the same. The major modality found to be used in all centers is group therapy. What varies across centers is the focus of the group therapy; some centers use a psychotherapeutic approach while others' groups are more didactic in nature. All in all, however, the private alcoholism treatment system is remarkably consistent in its mode of treatment for chemical dependency. WORKPLACE LINKAGES TO TREATMENT It follows from organizational theory that linkages among organizations are necessary for effective functioning. Establishing these linkages then becomes the first step in organizational survival. In the literature about EAPs, it is widely suggested that treatment providers are anxious to establish connections with EAPs and with industry. Such connections may increase the likelihood of a steady flow of patients from the workplace into treatment and, thus, are important relationships to maintain. The remainder of this chapter focuses on how treatment providers establish and maintain liaisons with the workplace.

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Establishing the Relationship: Pursuit of Workplace Referrals Generally speaking, there is a relationship between treatment providers and the workplace, and treatment centers are receiving patient referrals from EAPs and from other work organizations. If one peruses the EAP literature, one gets the impression that alcoholism treatment centers are very heavily dependent upon client flow from workplaces and are preoccupied with marketing services to them. These data indicate that this emphasis is less than EAP personnel presume in terms of actual client referral sources, but marketing to the workplace is a prominent activity. Some treatment centers seem to be more adept than others at obtaining referrals from the workplace. Somewhat surprisingly, the data reveal that 45 percent of the sampled centers receive 10 percent or less of their patients from EAPs or industry; only a small proportion of the centers in the sample (8 percent) receive the majority of their patients from these sources. These statistics indicate overall differences in the amount of workplace referrals to each center and point to the variability that exists in these referral patterns, which may result from geographic location and referral development efforts. In other words, EAP activity is not a constant across geographic regions, and some treatment providers are more active in the pursuit of workplace referrals than others. Some centers are more active in their pursuit of patients than others because they are newer to the community and do not have a longstanding reputation as a basis for client flow. Another factor is a large number of beds to fill; some centers must be more aggressive and comprehensive in their marketing of treatment services. Information was acquired regarding the various types of activities that treatment organizations will undertake to increase referrals from EAPs or industry. These endeavors include strategies such as offering a variety of free services designed for work organizations or establishing a marketing position within the treatment center oriented solely toward worksite contacts. The most frequent activity that treatment centers engage in to encourage workplace referrals is that of offering different services to companies free of charge. The services provided are usually educational in nature, aimed at both the supervisor population and the overall work force. For example, treatment personnel will go into a given company and give talks about chemical dependency to groups of employees. Many centers provide training for supervisors on how to identify a subordinate's possible substance-abuse problem and what actions to take when a suspicion arises. In addition, most centers distribute brochures and pamphlets about the issues surrounding chemical dependency to an organization's medical department or EAP. Beyond education is consultation where treatment centers use their expertise to help a work organization establish its own EAP. In this sample, 51 percent of the centers have helped one or more workplaces in this manner, although not all of these provide such services on a routine basis. Along with the expert training and educational classes offered, many treatment

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providers will perform clinical assessments for work organizations concerned about an employee with a possible substance-abuse problem. Most treatment centers (72 percent) will also conduct interventions in the workplace at no charge to the company. Supposedly there is no agreement that an employee who is assessed or with whom an intervention is staged will be admitted to the center involved in the assessment or intervention, but such a referral usually occurs if the center seems to be appropriate for the individual. The availability of these complimentary services, both educational and clinical, suggests that many treatment providers are presenting an attractive array of services in the hopes of increasing referrals from EAPs or work organizations. In addition to the free services offered, many treatment centers will reduce the cost of their services for employees in particular work organizations in order to present an appealing package when trying to establish long-term relationships with industry. Numerous centers make arrangements or preferred provider organization (PPO) agreements to give discounts to EAPs or industry. In this sample, 75 percent of the centers have PPO agreements with industry, and 53 percent of the marketing representatives mentioned that their centers offered discounts. Treatment centers seem to be responding to managed health care in work organizations by offering these discounts, yet many remain naive about the managed care concept. In the first draft of the interview, administrators were asked to respond to a question about managed health care in the workplace. There was such a lack of awareness surrounding the terminology that the question was changed to one concerning precertification. Most administrators expressed somewhat negative feelings about the precertification process; in fact, 83 percent mentioned that they have had problems with precertifications. Many (27 percent) agreed that the concept was a good one, but felt that the operationalization of it needed work. Two of the most frequently mentioned problems were that precertification was an obstacle to treatment for many who needed it (31 percent), and that the personnel responsible for conducting the precertifications were generally ignorant about chemical dependency (26 percent). Therefore, although treatment centers seem unsophisticated about the jargon, they are being exposed to the mechanisms or outcomes of managed health care policies and are responding to it by dealing with pre- and recertification as well as by offering discounts to combat the workplace's perceptions of high insurance outputs. Another strategy to establish linkages with EAPs and industry in an attempt to increase referrals from the workplace is the creation of a discrete marketing position. Of the centers in the study, 65 percent had someone in a marketing, community relations, or public relations position. The main job duty of this position was typically referral development, and the referral development was typically centered around work organizations. On the average, almost half the time of the marketing representatives was oriented to the workplace; 25 percent of their overall contacts were with EAPs, and 23 percent of their overall contacts were with work organizations without EAPs. Thus, this position provides a

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mechanism for establishing a greater number of interorganizational relations, and presumably it can be a critical link between the treatment provider and the workplace. Another formal link that some treatment centers have created with the workplace is the operation of an external EAP. When asked if they provide employee assistance services to companies without EAPs, 27 percent of the sampled centers responded affirmatively. It is possible that treatment centers enter into the arena of employee assistance provision to augment their patient census with insured patients. Such practices may be seedbeds for conflicts of interest, for both EAP and treatment ethics dictate that patients should be referred to the most appropriate facility considering their diagnosis and personal characteristics. Treatment centers involved in providing EAP services are quick, however, to assure others of their ethical practices, suggesting that any referrals to treatment through their EAP services are made on strictly objective criteria. Maintaining the Relationship: Response to Workplace Demands From the discussion above, it is clear that treatment centers are involved in many activities in their pursuit of relationships with EAPs and other work organizations. What remains to be discussed is how these relationships are nurtured so that both parties benefit from the linkage. Because EAP and workplace referrals are perceived by many treatment providers to be a desirable commodity, treatment centers oftentimes must be sensitive to requests and recommendations from work organizations if they wish to maintain a good working relationship. For example, work organizations have made various suggestions to treatment providers regarding the addition of services such as outpatient programs, aftercare services, and patient monitoring systems. Treatment providers vary in their willingness to respond to these external pressures. Some centers seem less willing to respond to the wishes of work organizations and, thus, have insulated themselves from having to react to them by diversifying their marketing to include other referral sources in addition to the worksite. However, most private treatment providers (53 percent) have made some sort of change in their operations because of appeals from EAPs. It is recognized that the causal relationship between industry demands and treatment changes is somewhat vague since some changes in treatment programming have been in response to trends in alcoholism treatment generally. Although these trends were possibly instigated by EAP pressure, there is not always a clear connection between the two. When asked about demands from EAPs and industry, many treatment administrators said that their centers have responded to these referral sources by instituting some changes in order to maintain the stability of the relationship. Several centers said that they improved their patient monitoring systems (19 percent), which suggests that EAPs desire more accurate communication about the progress of their clients in treatment. In fact, when marketing representatives

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were asked what EAPs look for or request from a treatment center, 40 percent replied that communication and progress reporting were extremely important. Of the centers reporting changes in response to EAP requests, many have gone so far as to implement new programs such as an outpatient program (11 percent), aftercare services (5 percent), or a patient follow-up system (12 percent). One of the latest trends seems to be that of offering a new combined program of inpatient and outpatient treatment so that employees can return to work more quickly. Also, several centers have chosen to reduce their length of stay (8 percent) or, as previously mentioned, have offered substantial monetary discounts in response to managed health care plans in the workplace. Overall, it appears that many private treatment providers act in response to suggestions from work organizations. One of the previously mentioned requests that is most often made of treatment centers has to do with communication flow. Keeping the lines of communication open and cordial may increase the probability that an EAP will refer to a particular center in the future. EAPs generally insist that they be kept informed of their client's progress while in treatment. To deal with this EAP need, treatment providers have initiated monitoring systems so that descriptive progress reports can be given at whatever time intervals the EAP wishes. If this type of communication is requested, treatment personnel phone EAPs as often as once a week to give updates on patient progress. Additionally, some EAPs are invited to attend patient staffing meetings with the treatment team. On occasion, EAPs require treatment centers to send progress reports while their client is in aftercare as well as during the course of treatment. EAPs typically are included also in discharge and the aftercare planning sessions that include the counselor and patient. Thus, EAPs usually are notified when an employee will be reentering the work force so that reentry can be coordinated to the extent possible. Responding to various suggestions and requests from EAPs indicates that this referral source is treated quite differently than other referral sources. In fact, other differences can be found when one looks at responses to a direct question about whether EAP-referred patients are treated differently. Most respondents initially replied " n o , " but they almost always placed a qualifier on their negations. For instance, all administrators said that patients were treated no differently in terms of rehabilitation but that EAPs typically were involved more in an information flow regarding the ongoing treatment and progress of their clients than other referral sources (42 percent), sometimes better records were kept on these patients (21 percent), the admission process was often expedited (12 percent), and sometimes it was admitted that more efforts were made to find an available bed for an EAP referral (6 percent). This differential treatment of EAP referrals suggests that private treatment providers are engaging in efforts to sustain established relationships with EAPs. Responses made to the various needs of the workplace indicate that treatment providers are working toward the maintenance of important interorganizational relationships. However, oftentimes there are factors that work against the main-

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tenance of a linkage. In this study, most treatment centers (62 percent) reported having problems when dealing with work organizations. The most frequently mentioned problem (31 percent) was that many companies are ignorant about chemical dependency. This ignorance very likely could hinder a center's ability to maintain a relationship with a worksite that might not be able to fathom the reason the relationship exists in the first place. An additional problem mentioned by centers (18 percent) concerned the lack of utilization of the treatment-workplace linkage (i.e., patients were not being referred from this source). Also, several administrators (16 percent) responded that their center's problem with work organizations was the limited or lack of insurance coverage for alcohol and drug treatment which, in all likelihood, would decrease the referrals to a given center. This limited resource exchange reduces the frequency of interactions between treatment providers and the workplace which, in turn, weakens the existing interorganizational relationship. CONCLUSIONS Several conclusions can be drawn from this study. First, a treatment-workplace linkage exists, and it is essential to the functioning of both workplace EAPs and treatment organizations. Without treatment centers, EAPs would have only support groups and private practitioners to refer to, and work organizations without EAPs would have no one to conduct inservice training, assessments, and interventions for them. On the other hand, without EAP and other work organization support, it might be difficult for private treatment centers to find a professional referral source that repeatedly came into contact with alcohol and drug cases, save possibly physicians. Although some centers appear to function adequately without the benefit of workplace referrals, these centers seem to be in the minority. A second conclusion that can be drawn from the data is that treatment providers are engaging in numerous activities to establish linkages with the workplace. Activities ranging from the provision of chemical-dependency seminars in the workplace to the ongoing pursuit of worksite referrals by one or more marketing representatives were reported in the sample. Moreover, the majority of centers (82 percent) reported that they had specific strategies designed solely to inform work organizations about their services. Furthermore, treatment centers are taking an active role in the maintenance of these interorganizational relationships once they have been established. The data presented substantial evidence that treatment providers are responding to workplace requests in an apparent effort to sustain a healthy resource exchange relationship with various work organizations. In investigating the nature of the treatment and workplace linkage, it becomes possible to deduce the consequences of that linkage on the intraorganizational structure and process of private treatment centers. For example, the desired alliance with EAPs and the workplace is related to a treatment center's creation of a marketing or referral development position. The addition of a marketing position is a change in organizational structure that may have been in response

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to either the need to initiate or preserve interorganizational liaisons with the workplace. In terms of the intraorganizational process, EAPs have impacted on the quality of treatment available. When marketing personnel were asked if they thought that the increase in the treatment center's transactions with EAPs had increased the quality of treatment, 51 percent responded affirmatively. It was mentioned that EAP growth had been somewhat responsible for the growth in the treatment industry, but also that the added competition in the alcoholism treatment field had increased the quality of the care provided. Also mentioned were several statements reflecting the beliefs that increased EAP activity has improved treatment quality by assuring better patient assessment at the onset of treatment, better patient monitoring during treatment, and better patient follow-up after treatment is completed. In addition, several of the reported responses to workplace demands resulted in changes in treatment delivery for many centers. Thus, it is evident that the interorganizational alliance with the workplace has impacted on the treatment center process. A final conclusion of the present study concerns the conflict between the two organizational types as opposed to the cooperation that has been summarized above. Conflict seems to exist over the functional boundaries of both EAPs and private treatment facilities. It appears as if both organizations are either overstepping or are unsure of their respective boundaries. Treatment centers seem to be offering employee assistance services to many companies without formally calling themselves an EAP service provider. The inservice training that many treatment centers provide for supervisors is very much like the educational training that an EAP offers. Further, the role that some centers have taken on in terms of assessment and intervention in the workplace may be viewed as direct competition with the services provided by EAPs. With regard to EAPs and their foray into the treatment centers' territory, 51 percent of the centers' marketing representatives said that external EAPs are not referring to alcohol and drugtreatment centers as much as they should, and 28 percent said that some of these external EAP service providers were acting unprofessionally by providing treatment themselves. This reaction indicates that some EAPs are also invading the functional arena of the treatment industry by providing counseling beyond the typical assessment sessions. With some evidence that EAPs are influencing what takes place in treatment, and that treatment providers and EAPs are overlapping roles, it is no wonder that some antagonism has sprung up between the two types of organizations. However, it is also obvious that EAPs and treatment providers need each other's resources, in most cases, which makes the linkage inevitable. NOTE Support from Grant No. R01-AA-07218 from the National Institute on Alcohol Abuse and Alcoholism, U.S. Public Health Service, for the data collection described in this chapter is gratefully acknowledged.

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REFERENCES Hall, R.H. (1977). Organizations: Structure and process (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall. Katz, D., and Kahn, R.L. (1966). The social psychology of organizations. New York: John Wiley & Sons. Levine, S., and White, P.E. (1974). Exchange as a conceptual framework for the study of inter-organizational relationships. In Y. Hasenfeld and R.A. English (Eds.), Human service organizations: A book of readings (pp. 545-561). Ann Arbor, MI: The University of Michigan Press. Pfeffer, J., and Salancik, G.R. (1978). The external control of organizations: A resource dependence perspective. New York: Harper and Row. Reed, P.G., and Sanchez, D.S. (1986). Characteristics of alcoholism services in the United States—1984: Data from the September 1984 National Alcoholism and Drug Abuse Program Inventory. Rockville, MD: U.S. Department of Health and Human Services, Division of Biometry and Epidemiology. Roman, P. (1988a). The disease concept of alcoholism: Sociocultural and organizational bases of support. Drugs and Society, 2 (3/4), 5-32. Roman, P. (1988b). Growth and transformation in workplace alcohol programming. In M. Galanter (Ed.), Recent developments in alcoholism (pp. 131-158). New York: Plenum Press. Roman, P., and Blum, T. (1985). The core technology of employee assistance programs. Almacan, 15 (3), 8-19. Roman, P., and Blum, T. (1987). Notes on the new epidemiology of alcoholism in the U.S.A. Journal of Drug Issues, 17, 321-332. Roman, P., and Blum, T. (1988). The core technology of employee assistance programs: A reaffirmation. Almacan, 18 (8), 17-22. Weisner, C , and Room, R. (1984). Financing and ideology in alcohol treatment. Social Problems, 32, 167-184.

21 ALCOHOLISM TREATMENT PROGRAMS AND THE WORKSITE: SOURCES OF CONFLICT—THE NEED FOR COOPERATION WILLIAM J . FILSTEAD

Alcoholism treatment programs and the worksite have, over the past 30 years, developed and implemented a number of separate as well as cooperative arrangements for addressing alcohol and other drug-use problems (Shain and Groeneveld, 1980; Trice, 1980; Dunkin, 1982). What typically began in a company as an alcohol-focused service often expanded into a paid EAP position. The focus of the service, over time, has also expanded. Broadbrush programs, covering a spectrum of personal problems beyond the scope of alcohol and other drugs, have emerged (Kurtz, Googins, and Howard, 1984; Ford and Ford, 1986; Roman, 1981). Presently, wellness and holistic health promotion programs, with services aimed at stress reduction, smoking cessation, weight control, and so on, are becoming the mode of addressing these personal problem concerns of employees and their dependents (Fielding and Breslow, 1983; Francek, Klarreich, and Moore, 1984; Roman and Blum, 1985; Roman, 1988). When it comes to treating alcohol or other drug problems of employees, employers are quite concerned about cost and quality. In recent years, with managed care specialists and preferred provider organization (PPO) arrangements, costs have become the primary concern—cynics would add, the only concern. With escalating health care benefits the push has been to reduce the cost of treatment services while maintaining both the quality and effectiveness of the services delivered. This connection between cost of treatment and the array of treatments available has fueled the debate about the relative effectiveness of inpatient versus outpatient treatment for these problems (Miller and Hester, 1986; Cotton, 1988; Saxe et al., 1983). Two topics are covered in this chapter: (1) the historical and evolving nature of the treatment services available for these problems and (2) present-day forces

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and constraints that impact upon and shape the nature of treatment services and the treatment provider-employer relationship. HISTORICAL BACKGROUND Since 1969, when I became active in this field, numerous events, trends, and themes have shaped and continually redefined the nature of the connection between the worksite and the treatment providers. Unfortunately, only a few references can be cited to support these changes. The announcement by the American Hospital Association in the mid-1950s, as well as its endorsement by the American Medical Association, that alcoholism is a disease was a significant milestone. This announcement gave legitimacy to the disease model of treatment and opened up the health care system to provide services to people with this problem. One cannot underestimate the sense of accomplishment felt in the alcoholism field when this position of medical legitimacy was achieved. Back wards of locked state mental health facilities no longer would be the only point of health care for alcoholics. Alcoholism had now moved into the mainstream of health care. With access to health care came the economics of health care costs. Health care coverage for alcoholism treatment was now available. This coverage continues today to be a point of debate and controversy. Although not all thirdparty payers jumped on the bandwagon to cover alcoholism immediately, over time, most insurance companies in most, if not all, the states, provided coverage for the hospital-based program of detoxification and inpatient treatment. An important point to note, and to come back to later, is that this coverage was for hospital-based treatment, rarely for outpatient treatment. Currently, much debate centers on the relative cost-effectiveness of inpatient versus outpatient treatment for these problems. The push presently is to provide most alcoholism services on an ambulatory basis. Between the mid-1950s and the formation of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in 1970 (Comprehensive Alcohol Act, 1970), there was no great explosion of treatment services or patients seeking treatment for alcoholism. The health care system remained relatively unchanged in its response to this problem. However, if alcoholism was treated, the fact remained that treatment could occur in a hospital and the cost of such care could be covered by insurance. This sense of gaining an equal status to other illnesses and to having health care and insurance coverage available for those programs firmly established alcoholism as a legitimate disease to be recognized and reckoned with by the health care system. With the formation of NIAAA, the extensive social, physical, and economic costs were laid out for all the country to see. In fact, the U.S. Senate hearings were, in part, a vehicle for educating society about the signs, consequences, and scope of excessive alcohol use. Senator Harold Hughes, from Iowa, spearheaded this legislative process.

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In the years during which the NIAAA was emerging as an organizational entity, the Social Research Group produced two monographs, American drinking practices (Cahalan, Cisin, and Crossley, 1969) and Problem drinking among American men (Cahalan and Room, 1974). These epidemiologically focused books painted the broad scope of these alcohol misuse problems. These data were used to compute the social and economic costs of these problems to society in the First special report to the United States Congress on Alcohol and Health (Rosenberg, 1971). With this epidemiological data incorporated into the political processes to create NIAAA, the number of alcoholics doubled overnight—from the National Council on Alcoholism's (NCA) figure of 5 million to NIAAA's figure of from 10 to 12 million. In addition to the alcoholics, there were the millions of affected family members. However, the key figure in this portrait of impact to society was the cost to industry. Cost caused by or related to alcohol misuse and alcoholism in the worksite would represent the principal point of intervention for the alcoholism field. The First special report to Congress placed the cost of alcohol problems to industry at $10 billion, the Eighth report to Congress places the costs at $55 billion. These industry/worksite costs are for alcohol only, not for any other substances or for the health care costs to treat these problems. One needs to be aware of the sociopolitical processes used to arrive at such cost calculations (Fillmore, 1984). Given these costs to industry for missed work, lost productivity, increased health care costs for the employee and his or her dependents, what better focal point for the alcoholism treatment programs (ATP) to focus upon? By emphasizing the worksite, ATPs would be helping individuals, helping employers, and, in general, returning to the worksite productive employees. Not lost in this view was the potential for an ongoing relationship between companies and ATPs to address the future needs or recurring problems of employees. It is a relationship that benefits all parties—worksite, providers, and the patients or employees. The EAP became, in part, a natural liaison between the worksite and the ATP. Although the function, purpose, and scope of EAP-related activities have evolved over the years (Roman, 1981), it was clear early on that a company was defined as ' 'progressive and forward thinking'' if an EAP existed to address these matters. Today, cost reduction and downplayed usage of inpatient alcohol and other drug abuse services is center stage. It is one thing to have these programs in place for employees; it is quite another to demonstrate the cost-effectiveness of such programs. In today's climate, for these programs and services to exist for employees, their costs have to be reduced. The victory—and by all accounts it can be seen as a major victory for the alcoholism field—of having alcoholism recognized as a disease may have, in the long run, contributed to a myopic view of what the treatment should or could be. Initially, hospital-based care for alcoholism dominated as the only service available. This was the case, in part, because third-party providers would cover

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Table 21-1 Trends in Alcoholism Beds and Services 1980

Number of hospital-based inpatient treatment programs

1

Number of outpatient programs

Number of alcohol/drug units in hospital Number of alcohol/drug unit beds

NOTE:

1

% of Increase

1986

2

506

1,039

105%

1,182

1,342

13%

1978

1987

% of Increase

465

1,148

147%

16,005

34,364

115%

Estimated 1.71 billion for alcohol and 1.3 billion for drug treatment, based on a survey of 6,000 providers.

American Hospital Association statistics reported in Medical World News (12,26,88) pp. 53-54.

o NIDA/NIAAA, 1987 National Drug and Alcoholism Treatment Unit Survey. Division of Biometry & Epidemiology, Rockville, Maryland.

NIAAA,

little or nothing else and providers of treatment did not conceptualize any other ways of delivering services. The broadening of treatment services has come primarily at the request of payers for services and the referral sources, rarely from the alcohol treatment field itself. In a publication of NIAAA's Division of Biometry and Epidemiology, the trend in growth for hospital-based alcoholism treatment units and the lack of similar growth in outpatient services is noted (Alcoholism and Drug Abuse Week, 1989a, 1989b). Between 1978 and 1987, the number of hospital units providing alcoholism services grew from 465 locations to 1,148 locations, a 147-percent increase in hospital-based units.* This same growth pattern is true for the number of beds available for alcoholism treatment. In 1978, there were 16,005 hospitalalcohol use beds, whereas, in 1987, there were 34,364 beds, an increase of 115 percent. The data presented by NIAAA were derived from the American Hospital Association's (AHA) annual surveys. For 1987, 6,281 hospitals were surveyed. According to the AHA data, hospital-based inpatient programs for alcoholism more than doubled (from 506 to 1,039) between 1980 and 1986. On the other hand, outpatient services for this same time period increased by 13 percent, from 1,182 to 1,342 locations (see Table 21-1). It is this dual dilemma, increased

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hospital-based treatment and a lack of ambulatory programs, which is at the heart of the conflict between the alcohol treatment field and the worksite. Hospital and residential freestanding programs have come to dominate, disproportionately, the treatment services that are available to individuals with alcohol-related problems. The perceived imbalance between residential and outpatient services has caused critics to question the need for such services (Glasscote et al., 1967; Miller and Hester, 1986; Saxe et al., 1983). In fact, the questions of effectiveness and costs of care are very current. The challenge has been made to the alcohol treatment providers: reduce cost, document effectiveness, clarify which patients need what type(s) of treatment, and offer a broader spectrum of services and interventions. Either the alcohol treatment industry will employ some type of self-regulation to correct this state of affairs or externally mandated and enforced regulations will be imposed. CONTEMPORARY ISSUES AND CONCERNS People seeking help for alcohol-related problems are caught in a cross fire between the providers who promote what they feel is needed (their program) and the payers who want more cost-effective programs, primarily on an outpatient basis. Hospital-based and residential services are the least attractive treatment alternatives, as seen from the perspective of those charged with the responsibility of reducing costs. This debate is central to the cost concerns of the worksite because their employees will become the patients in these treatment programs. The worksite, EAPs, and others do not want the same expensive inpatient services being offered to all individuals who seek treatment for alcohol-related problems. No one can argue with this position. Uniform treatment for all who have an alcohol or other drug problem makes no sense. Clearly, not all individuals need the standard 28-day hospital-based program, but some do. Likewise, not all patients need outpatient services, but perhaps many do. This clash between clinical needs and treatment costs places the employee in an untenable position. Both sides must realize that what the person needs is in the best interests of both the providers of the services and those who pay for services. Patients should receive only those services they need and have to pay only for what they need to get. The state of this relationship between the providers of services and the payers (worksite) can be characterized in terms of issues that bear upon the concerns of each side and the issues that must be addressed if this relationship is to improve. First, cost-effectiveness, when raised by EAPs or managed care consultants, more often than not can be translated to mean "less cost is best treatment." The less in this phase is cost reduction or elimination. Thus, if services cost less, this is the best situation. Although this is an exaggeration, cost considerations often override service decisions or treatment needs. For example, it is not unusual for worksites to have a set of inflexible restrictions on what services,

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what settings, and what time frames will be eligible to receive reimbursement. Any deviation from this prescribed set of services places the reimbursement for care in jeopardy. Alcohol treatment programs, on the other hand, have to demonstrate differential patient placement according to clinical need. Until there is a range of viable treatment options available for patients, the worksite has every right to question the competence and capabilities of the treatment providers to deliver quality services. Second, "flex-programming" is an oxymoron that crystalizes the confusion in thinking as to the nature of present-day alcoholism treatment services. In an effort to break the standardized 28-day hospital residential treatment cycle, a combination of inpatient days and weeks of outpatient sessions, e.g., "two by four,'' has been proposed as a creative response to the inflexible 28-day treatment cycle. However, it would seem obvious that replacing one inflexible service— the 28-day inpatient treatment for everyone—with another inflexible service— two by four for everyone—is not a move in the direction of flexibility. Why propose this switch if it is still recommended for everyone? What is it about individualizing treatment that seems difficult for providers to understand? This matter is at the ideological heart of service providers. Treatment people believe (and it is important to stress the point that it is a belief because there is no data to support this belief), that all patients, regardless of clinically relevant individual differences, need a set of time focusing on their addiction. This belief in a duration of time, common for all, focusing on the nature of addiction in a generic way, rather than emphasizing the unique individual facets of the patient's clinical condition, is central to the treatment of addiction. It is the core tenet that underlies what and how treatment providers think about and do their work. Furthermore, the residential inpatient model is felt to be a superior format for treatment because in the therapeutic community milieu of other patients everyone can more effectively confront and support each other in their efforts to address their addiction. The counterpoint to this view is the patient-treatment matching hypothesis (Glaser, 1980) that places a premium on identifying the clinical needs of the patient in a manner that allows for the individualization of treatment. Although there is a clear need for a variety of standard activities, services, and programs and treatment options, the best treatment is the one that sorts, selects, and develops a treatment plan that meets the patient's needs on a patient-by-patient basis (McLellan et al., 1983; Rist and Watel, 1983; Rollnick and Heather, 1982). In simple terms, the clash is over the extent to which A = addiction is emphasized at the expense of I = individualizing during this treatment process experience. Providers feel an Ai model should be the emphasis. Others may promote an la emphasis. Some of both seems reasonable. The debate is over the proportion of each. Third, given the above remarks about costs and the focus of treatment, it is

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not a surprise that much energy and effort are directed at who controls the treatment process. Who has what power? Obviously, reimbursement plans have the ultimate power because they dictate what will and will not be covered. However, these plans are negotiable. Therefore, employers can decide what types of programs and services they feel are needed. Furthermore, they can also decide how much they wish to pay for such coverage. Managed care specialists, or health care consultants, sell their expertise to evaluate the need for treatment and what treatments are most likely to be needed by the employee. This middleman arrangement leads to many problems, which, although they are resolvable, may make the process of helping impaired employees all the more difficult. Rather than discuss the interrelationship among these three participants (the employer, the managed care specialist, and the provider of care), it is more important to stress a few principles of operation that could make this process of helping employees as painless and effective (in terms of both cost and outcome) as possible. 1. Various treatment options and intensity of treatment services must be available and must be covered by the reimbursement package. Such is generally not the case as matters presently stand. 2. Patients should get only what they need, and the employer should have to pay only for what the patient really needs to get. 3. Providers of service should be expected to articulate the criteria used to evaluate the type and level of care needed. One must be very leery of the provider who has only one level of care and one type of treatment. Likewise, providers should be very leery of an employer who will cover only one type of treatment service. 4. Cost-effectiveness means paying for what is needed in the belief that what is needed will make a difference. Providers of service can be accountable only for matching the patient to the services needed; providers are not expected to be 100 percent successful. However, if there is a commitment to delivering services matched to the clinical needs of the patient, one would expect the best chance of obtaining positive results. 5. Need comes before costs; but unclear or unsubstantiated clinical needs should never be accepted as standard clinical care. Treatment programs and providers must live up to their end of the bargain: to deliver the needed clinical services in the most professional and cost-efficient manner. Ongoing program evaluation will aid in determining what works the best for whom. Employers should start to ask for copies (if they do not already have them) of the program's attempts to evaluate its services. Be cautious of any program that has never tried to evaluate its services or that claims astronomically high rates of success. CONCLUSION In many ways the relationship between treatment providers and worksites can be viewed as more conflictual than cooperative in determining the need for

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substance-abuse services. The conflict centers on the cost-effectiveness debate. The level of trust and professionalism on the part of both sides is generally good, but it could be improved. The clinical needs of the patients must be the central concern of both parties. What services, if any, and what types of treatment over what length of time are judgmental and debatable matters. Standard cookbook responses to the clinical status of patients, which give lip service to "individualizing needs," must be challenged. Unfortunately, the patients are caught in this struggle between providers and the worksite reimbursement system. Treatment providers are facing tough questions regarding treatment effectiveness, the comprehensiveness of services, the scope of assessment procedures, and the ever-expanding spectrum of "problems" that are now encompassed within a generic addiction model. Accountability is critical to the reputation of a treatment provider. Accountability is a prerequisite to quality services. More than ever before treatment providers are faced with the demand to prove that their services are effective. Worksites, particularly EAPs, although remaining cost conscious, should concentrate their efforts on seeing to it that employees in trouble because of substance abuse receive the type of assessments that maximize the chances of targeting the problems that need to be addressed in the most appropriate treatment settings. EAPs or managed care specialists should not dictate the course of treatment before seeing the patient and determining the nature and scope of the clinical needs. Industry must participate in the deliberations about intervention options rather than mandate the course of care without benefit of this collaborative exchange of information between themselves and the providers of services. Employers should demand quality of care, but not expect providers to do employers' jobs or to perform miracles. If both the treatment provider and the employer keep the focus on what is best for the employee, a more cooperative spirit of collective action will prevail. NOTES The opinions expressed in this chapter are those of the author and do not represent an official position of Parkside Medical Services Corporation. 1. I am not aware of similar data for residential nonhospital facilities. Impressionistically, the growth curve of nonhospital facilities appears to be greater than for hospital units, given the fewer regulatory issues associated with freestanding facilities. REFERENCES Alcoholism and Drug Abuse Week. (1989a, March 8). NDATUS survey shows extensive funding from variety of sources, vol. 1, 5. Alcoholism and Drug Abuse Week. (1989b, March 15). Hospital beds for alcoholism/ chemical dependency doubled, vol. 1, 10, 5. Cahalan, D., Cisin, I., and Crossley, H. (1969). American drinking practices: A national survey of drinking behavior and attitudes. New Brunswick, NJ: Publications Division, Rutgers Center of Alcohol Studies.

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Cahalan, D., and Room, R. (1974). Problem drinking among American men (Monograph No. 7). New Brunswick, NJ: Rutgers Center of Alcohol Studies. The Comprehensive Alcohol Abuse and Alcoholism Prevention Treatment and Rehabilitation Act of 1970. (PL-96-616, 84; Stat. 1848). Cotton, P. (1988, December 26). Detox program called wasteful. Medical World News, 53-54. Dunkin, W. (1982). A brief history of employee alcoholism/assistance programs. LaborManagement Alcoholism Journal, 11, 165-168. Fielding, J., and Breslow, L. (1983). Health promotion programs sponsored by California employers. American Journal of Public Health, 73, 538-542. Fillmore, K. (1984). Research as a handmaiden of policy: An appraisal of estimates of alcoholism and its costs in the workplace. Journal of Public Health Policy, 14, 40-64. Ford, J., and Ford, J. (1986). A systems theory analysis of EAPs. Employee Assistance Quarterly, 2, 37-48. Francek, J., Klarreich, J., and Moore, C. (Eds.). (1984). The human resources management handbook: Principles and practice of EAP. New York: Praeger. Glaser, F. (1980). Anybody got a match? Treatment research and the matching hypothesis. In G. Edwards and M. Grant (Eds.), Alcoholism treatment in transition (pp. 178— 196). Baltimore, MD: University Park Press. Glasscote, R., Plant, T., Hammersley, D. et al. (1967). The treatment of alcoholism: A study of programs and problems. Washington, DC: Joint Information Service of the American Psychiatric Association and the National Association for Mental Health. Kurtz, N., Googins, W., and Howard, C. (1984). Measuring success of occupational alcohol programs. Journal of Studies on Alcohol, 45, 33-45. Masi, D. (1984). Developing employee assistance programs. New York: American Management Association, Inc. McLellan, A., Woody, G , Luborsky, L. et al. (1983). Increased effectiveness of substance abuse treatment. A prospective study of patient-treatment matching. Journal of Nervous and Mental Disorders, 171, 597-605. Miller, W., and Hester, R. (1986). Inpatient alcoholism treatment. American Psychologist, 41 (7), 794-805. Petrakis, P. (Ed.). (1987). Sixth special report to Congress on alcohol and health (ADM87-1519). Rockville, MD: U.S. Department of HHS. Rist, F., and Watel, H. (1983). Self-assessment of relapse risk and assertiveness in relations to treatment outcome of female alcoholics. Addictive Behaviors, 8, 121— 127. Rollnick, S., and Heather, N. (1982). The application of Bandura's self-efficacy theory to abstinence-oriented alcoholism treatment. Addictive Behaviors, 7, 243-250. Roman, P. (1981). From employee alcoholism to employee assistance programs. Journal of Studies on Alcohol, 42, 244-272. Roman, P. (1988). Growth and transformation in workplace alcoholism programs. In M. Galanter (Ed.), Recent developments in alcoholism (pp. 131-158). New York: Plenum Press. Roman, P., and Blum, T. (1985). The core technology of employee assistance programs. Almacan, 15, 8-12.

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Rosenberg, S. (Ed.). (1971). First special report to the United States Congress on alcohol and health. Washington, DC: Department of Health, Education and Welfare. Saxe, L., Dougherty, D., Esty, K., and Fine, M. (1983). The effectiveness and costs of alcoholism treatment (Health Technology Case Study No. 22). Washington, DC: Office of Technology Assessment. Shain, M., and Groeneveld, S. (1980). Employee assistance programs: Philosophy, theory and practice. Lexington, MA: Lexington Books. Trice, H. (1980). Applied research studies: Job-based alcoholism and assistance programs. Alcohol Health and Research World, 4, 4-6.

PART III PRACTICAL IMPLICATIONS OF STRATEGIC ALTERNATIVES IN DEALING WITH ALCOHOL PROBLEMS IN THE WORKPLACE

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22 IMPLICATIONS FOR INTERVENTION AND PREVENTION IN THREE STREAMS OF EAP-RELATED RESEARCH HARRISON M. TRICE

This chapter brings together three streams of research that relate to the overall theme of alcohol problem intervention in the workplace. The first stream is directed toward the outcomes of a worksite intervention popularly called "constructive intervention" or "constructive confrontation." It stands in sharp contrast to recent efforts to deemphasize prevention and alcohol problems in workbased programs (Roman, 1981b) and to replace these features with self-referrals, a questionable notion at best (Trice and Sonnenstuhl, 1988a; Sonnenstuhl, 1982, 1986; Sonnenstuhl, Staudenmeier, and Trice, 1988). The second stream consists of research that attempts to identify contributions of worksites to the etiology of drug-abuse problems such as alcoholism. This risk factors approach has only recently received systematic attention, but obviously the findings from this stream have prevention implications. Workplace factors should be included with other risk sources, such as genetic influences and family dynamics, personality and emotional risks, and social class and economic forces, in a search for the etiological forces in alcohol abuse. In such a context, the lessening or elimination of work-based risks would be a contribution to prevention. A third stream of relevant research, which can be labeled research utilization, focuses upon those processes that function to bring about the actual use of research findings in work organizations. It is patently obvious that unless the knowledge and information present in these two other streams are, in some form, utilized, they will be of little, if any, consequence. This approach pays considerable attention to linking roles, and raises the possibility that well-trained employee assistance program (EAP) workers might fill that role. In this connection, I briefly review the tentative findings of our recent, ongoing research on the socialization of EAP workers and raise the possibility that these workers' activ-

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ities may be the link between research findings, both about intervention and prevention, and their actual use in work organizations. RESEARCH ON CONSTRUCTIVE INTERVENTION IN THE WORKPLACE This first stream focuses on testing the conceptual position that natural influences in the workplace—administrative setups, occupational subcultures, and union structures—can exercise motivational influences on drug-abusing and neurotic employees that weaken and shrink their intense denial syndrome of exaggerated guilt, rationalizations, and manipulations (see Sonnenstuhl and Trice, 1986, for a comprehensive review). The position argues that this syndrome acts as a potent and pervasive barrier to desirable changes in behavior, and that unless it is weakened and blunted, there is little, if any, chance of recovery. Further, it argues that the workplace provides a natural context, and agents, with which to challenge and dilute the syndrome. This is the case because job performance is inevitably impaired, early on, in many behavioral problems. Such impairment, readily denied by the sufferer, becomes the legitimate basis for an intervention that directly confronts this denial syndrome. Thus, the constructive intervention strategy is conceived of as "an interactional process whereby an individual's behavior is modified to conform to the rules or standards of groups to which he belongs" (Burgess and Bushnell, 1969, 275). That is, the intervention acts not as a punitive measure, but as a socializing force (O'Reilly and Weitz, 1980) whereby the problem-drinking employee, in effect, learns new forms of behavior, namely, to perform adequately in social roles. In the process, it is likely that problem drinking will subside. The strategy encourages such social learning by exposing the employee to specific prescriptions from one of the powerful "groups which control individuals' major source of reinforcement and punishment and expose them to behavioral models and normative definitions" (Akers et al., 1979, 638). This approach, moreover, argues that in the process of bringing reality to the awareness of the employee, constructive opportunities to provide emotional support and therapy emerge. The intervention strategy rests on a combination of progressive, positive discipline—already in place in many work settings—with provisions designed to motivate problem-drinking employees to rehabilitate themselves. Also, the combined strategy of confrontation on poor performance and constructive help and support was designed to keep problem-drinking employees in the work setting where organizational influences can continue to operate in the form of a support system. The strategy requires that the supervisor or occupational peers hold a number of discussions with an employee whose performance is unacceptable. In the confrontational part of the initial discussion, the employee is given the specifics of unacceptable work performance and told that continued unacceptable performance is likely to lead to formal discipline. In the constructive part, employees are reminded that practical assistance is

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available through an employee assistance program. Subsequent steps in the process depend on the response of the employee. If performance improves, nothing happens; if unacceptable performance continues, several more informal discussions follow. The constructive part of the informal discussions (1) expresses emotional support and group concern about the employee's welfare, (2) emphasizes that employment can be maintained if the employee performs better in the future, and (3) suggests an alternative course of behavior that the employee can take to regain satisfactory work performance. The confrontational part of such discussions (1) reiterates expectations of work performance, (2) reminds the employee that he or she is not fulfilling these expectations and that formal sanctions will follow if expectations continue to be violated, and (3) establishes some distance between the employee and other employees who are meeting expectations, thus setting the stage for further sanctions if needed. Several studies have examined the job performance of alcoholics who were referred to treatment by their supervisors under the constructive intervention strategy. Typically, these studies measured employees' performance several years before and several years after rehabilitation. Some researchers in the 1960s and 1970s compared problem-drinking employees who experienced the constructive intervention strategy of their employers with similar employees who went voluntarily. (For an overall review of these studies, see Trice and Beyer, 1982.) A prominent example is a study by Margaret Heyman (1976, 1978) who collected data from alcoholic employees who had experienced degrees of constructive confrontation. Her data show a significant relationship between the intervention and improved work performance. Two Canadian studies found much the same thing. D. Finlay (1972) concluded that "crisis level anxiety" was a major factor in making alcoholic employees accessible to treatment. E. Freedberg and W.E. Johnston (1978) described a year-long follow-up study of 365 alcoholic clients, a majority of whom had received confrontations from their employers about inadequate job performance. They concluded that marked improvements were noted on four dimensions of job performance. Overall, the results of these studies have been somewhat mixed, but clearly they lean toward the general hypothesis that those alcoholic employees who experience the intervention are more likely to improve from their alcoholism and improve their work performance than those who did not experience it. These results are similar to those found by Griffith Edwards (1977) and his associates. They compared a group who received constructive advice with those who received alcoholism treatment. The advice intervention was remarkably similar to the constructive confrontation intervention available in the worksite. They concluded that the advice intervention had been as effective as the more costly, elaborate treatment. During the 1980s two studies went beyond the before-after designs of earlier research. A quantitative study of the effectiveness of the intervention featured a large nationwide sample and the use of multiple regression analysis to assess

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the effectiveness of the intervention (Trice and Beyer, 1984a; Beyer and Trice, 1984). Data were collected from two national samples of over 600 managers in a large corporation who had dealt with problem drinkers and with other problem employees, such as abusers of marijuana and amphetamines, sufferers from anxiety disorders, e.g., the phobias, and employees with recurring and debilitating depressive disorders. Oral discussions containing both constructive and confrontational topics were positively associated with the employees accepting help and with better work performance following intervention for both samples of employees. However, more severe forms of discipline—written warnings, suspensions, or discharges—were negatively associated with work performance following intervention in both samples. The results suggest that the strategy is most effective when repeated discussions balance both constructive and confrontational elements and that the presence of the alcoholism policy encouraged supervisors to take more actions with problem drinkers and legitimated those actions. H.M. Trice and J.M. Beyer found that 75 percent of problem drinkers and 55 percent of other troubled employees improved their job performance as a result of the strategy and concluded, "These results suggest that it is not just the actions taken with problem-drinking employees that produced desired outcomes, but also the legitimacy and predictability accorded these actions by the presence of a formal policy" (1984a, 404). The other study was an ethnography of occupational referrals made by peers into a program that featured the constructive confrontation strategy, but within the makeup of a specific occupation, not in the managerial hierarchy of a work organization. Data from the Tunnel and Construction Workers Union (Sonnenstuhl and Trice, 1987) revealed an occupational community characterized by a heavy-drinking culture. The constructive confrontation strategy was introduced into this culture through a peer-based counseling program. Observations of this interaction up close, over an 18-month period, produced the tentative conclusion that there had been a decided reversal of the heavy-drinking culture in this occupation. Labor economists have taken a different approach to an assessment of the strategy. Underlying worker behavior, they argue, are economic incentives and degrees of supervisory intensity (Leonard, 1987). Put in practical terms, "[E]mployers brandish two weapons in their battle against work indolence: supervision and economic incentives" (Hutchens, 1988, 18). One form of indolence, or "shirking," is on-the-job drinking, according to Hutchens. Using data from the 1972 Quality of Employment Survey, he tested whether those employees "intent upon on-the-job drinking" were more dissuaded from doing so by economic incentives in their jobs, such as relatively higher wages and bonuses, than by "supervisory intensity." Hutchens concludes that employees prone to shirk by on-the-job drinking may essentially ignore the future prospect of wage or pension loss, but carefully weigh the immediate embarrassment of getting caught in the act. In this case, although higher

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wages do not influence behavior, supervision has a dramatic effect. . . . Although the theoretical argument linking economic incentive to shirking is eminently reasonable, one wonders whether—at least for some forms of shirking—supervision is not the employer's weapon of choice. (1988, 19) J.S. Leonard (1987), using data from a survey of employment conditions in the high-technology sector of one state, also failed to find that economic incentives are a practical alternative to supervision. Labor arbitrators increasingly are also supportive of employee assistance programs and the constructive confrontation process (Denenberg and Denenberg, 1983; Sonnenstuhl and Trice, 1986; Miller and Oliver, 1988). Traditionally, arbitrators, who were forced to decide whether employers had treated alcoholic and emotionally disturbed employees fairly, simply asked whether the employees had been disciplined in accordance with management and labor's collective bargaining agreement. If the answer was "yes," the arbitrators let the discipline stand; if not, they reversed management disciplinary action. In some instances, activist arbitrators, who considered alcoholism or emotional disorders as illnesses, would reverse management's disciplinary actions with the proviso that they accept treatment and resolve their problems. Among today's arbitrators, EAPs are perceived as a middle ground between these two extremes. Arbitrators look favorably upon the fact that employees are disciplined on the basis of performance and that, at each step of the disciplinary process, employees are offered help. If these conditions are met, arbitrators will generally let a disciplinary action stand because the employers, by offering help, have met their obligations to the employee. Equally relevant here is whether the supervisors' use of management-initiated policies such as EAPs is related to the presence of a union, the power of any union present, and supervisors' awareness of the union's position on these programs. J.M. Beyer, H.M. Trice, and R.E. Hunt (1980) report on an analysis of interview data from supervisors in 71 federal installations, and from both national and local offices. The analysis indicated that the supervisors' awareness of a union's position was positively related to use of employee assistance programs, as were certain aspects of union power. The actual presence of a union was also associated with greater use of the program. RISK FACTORS IN THE WORKPLACE: PREVENTION IMPLICATIONS The second stream of research attempts to delineate workplace factors that, if experienced, may put employees at risk of alcohol and other drug abuses, as well as behavioral neuroses. If these could be somehow lessened or eliminated, preventive forces would be forthcoming. Work organizations are very prominent cultural entities and, as such, embrace their own drinking norms, rationales, and social controls. The four perspectives presented here, distilled from published

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research, highlight the importance of norms, social controls, and learned rationales for understanding workplace drinking behavior. The four perspectives are cultural, social control, alienation, and work stress. (See Trice and Sonnenstuhl, 1988b, 1990, for a more detailed discussion of these perspectives.) Although a growing research literature on workplace risks is associated with alcohol abuse and dependence, the studies as a whole suffer from numerous research problems. Generally, they are poorly conceptualized and operationalized, contain numerous sampling problems, and rely principally upon bivariate statistical analyses. Summarizing the state of the art, D.M. Herold and E.J. Conlon observed: while one's intuition or "gut" says that the workplace can be a contributor or cause of alcohol abuse, we seem to be a long way from clearly demonstrating this proposition or theoretically explaining just how such a result can come about. (1981, 355) According to the cultural perspective, administrative and occupational subcultures develop norms about what constitutes appropriate drinking. Historically, both cultures have supported drinking on the job (e.g., Sullivan, 1906; Winkler, 1968; Rorabaugh, 1979). Today, policies vary widely (Staudenmeier, 1987). In some, temperance is the norm; in others, heavy drinking, which may lead to alcohol abuse and dependence, is encouraged. Administrative support for heavy drinking may permeate an entire organization or be confined to a specific department or group. For instance, drinking plays a central role in military organizations, where personnel are often required to attend an endless round of parties and are encouraged to toast minor, major, good, bad, and indifferent occasions with alcohol (Bryant, 1974; Pursch, 1976; see also Molloy, 1989, for a discussion of alcoholic merchant vessels). Similarly, heavy drinking may be encouraged at business lunches, conferences, office parties, and managerial retreats (Fillmore, 1981; Roman, 1982b) or among specific groups of workers who believe that it promotes health and prevents industrial disease or is in some other way functional (Hayhurst, 1938; French and Magee, 1972; Trice, 1965). For instance, in a study of unemployed automobile workers, G.M. Ames and C.R. Janes found that the workers had evolved a well-established drinking culture with a "well-developed system of beliefs about alcohol use that made heavy work-related drinking acceptable for enhancing conviviality and interpersonal communication" (1987; 953) and that this workplace culture was a significant factor in promoting heavy and problem drinking. Many occupations, especially close-knit occupational communities (Salaman, 1974), may view heavy drinking as "normal" rather than "pathological" (Cosper, 1979;Pilcher, 1972; Applebaum, 1984;LeMasters, 1975; Slatery, Alderson, and Bryant, 1986; Riemer, 1976; Gamst, 1980; Whitehead and Simpkins, 1983; Mars, 1987; Olkinuora, 1984). For instance, drinking is an integral part of the Tunnel and Construction Workers' (i.e., Sandhogs) culture, where it reflects the heavy-drinking practices generally associated with mining and cements group

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solidarity (Sonnenstuhl and Trice, 1987). Generally, research suggests that those workers who are heavily involved in work-based social support networks drink more heavily and have more drinking problems than those without such social support, even when the work is intrinsically rewarding (Seeman and Anderson, 1983; Seeman, Seeman, and Budros, 1988). Evidence also suggests that people who have had rewarding experiences with alcohol may gravitate or drift into occupations with heavy-drinking cultures (Hitz, 1973; Schuckit and Gunderson, 1974; Plant, 1978, 1981) and conversely that those who do not enjoy drinking often leave such heavy-drinking occupations (Plant, 1978, 1981). Some studies (Mensch and Kandel, 1988; Crowley, 1985) report finding no relationship between occupation and alcohol and drug use. These studies, however, do not define occupation in cultural terms; rather, they define occupations structurally by lumping workers with similar job titles and characteristics into such census categories as "professional and technical workers," "managers and administrative except farm," "sales workers," "clerical workers," and so on (Freidson, 1986). Combining workers into such categories lumps people together who do not share common beliefs about work or drinking, and it confuses occupation, a cultural entity, with the structural features of work. This procedure violates the basic principles of standard analysis which requires that all categories be discrete entities. Under such circumstances, one would expect to find only spurious relationships between occupational culture and drinking practices. Overall, drinking continues to be an integral part of work life (Roman and Trice, 1976). Consequently, administrators and occupational members feel ambivalent about adopting and implementing policies to control drinking behavior (Beyer and Trice, 1978). These attitudes perpetrate heavy-drinking cultures. The social control perspective predicts that those characteristics which weaken workers' integration into, or regulation by, the work organization are likely to put them at risk of developing alcohol problems (Trice and Beyer, 1982). Trice and P.M. Roman argue that two general types of workplace risks lessen social control: the absence of supervision and low visibility of job performance (1978; 101-2). They do not allege that these factors produce alcohol abuse and dependence; rather, they state, "The employee must already have had rewarding experiences with alcohol and drugs before these risk factors are relevant" (1978, 101). Consequently, the employee prone to heavy drinking gravitates toward situations where he is relatively free from supervision and evaluation. Mobile jobs, for instance, reduce both supervisors' and co-workers' opportunities to observe and evaluate employees' performance (Trice, 1965; Roman, 1981a; Trice and Beyer, 1981), "giv[ing] an alcoholism-prone personality a job situation within which his tendency can easily develop" (Hitz, 1973, 505). Consequently, railroad workers, who spend a great deal of time away from home and have little contact with their supervisors, are more likely than their stay-athome peers to develop alcohol problems (Mannello and Seaman, 1979). Similar findings are also reported for entertainers, commercial travelers, seamen, and armed services personnel, all of which are jobs characterized by "mobility and

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consequent estrangement from the stabilizing influence of home life" and work life (Murray, 1975, 24). Ames and Janes' study demonstrates how a lack of supervision and low visibility of performance contribute to the development of a workplace drinking culture. They found that "social control in the factory was inconsistent, in many cases ineffectual, and quite often a source of stress and anxiety" (1987; 953). Managers put quantity ahead of quality of work, turning a blind eye toward onthe-job drinking as a trade-off for increased productivity. In addition, poor labor and management relations made it almost impossible to discipline workers for poor job performance, particularly when it was related to excessive alcohol consumption. These conditions, inconsistent performance standards and inability to discipline, made for a relative lack of social control that allowed the drinking culture to flourish. Shift work (Smart, 1979), unemployment (Brenner, 1975; Barnes and Russell, 1977; Ojesjo, 1980; Jacobson and Lindsay, 1980), and retirement (Minnis, 1988; Rosen and Glatt, 1971; Schuckit and Miller, 1976) are also associated with increases in drinking and alcohol problems. Shift work reduces workplace controls by disrupting the natural rhythm of supervision and evaluation. Shunted from one supervisor and group of workers to another, the individual prone to heavy drinking may evade detection and feedback from boss and peers for years. Unemployment and retirement, on the other hand, remove individuals from all of the workplace's sanctions for regulating drinking behavior. Retirees, shorn from group support and reinforcement of appropriate drinking, may turn to alcohol to cope with the problems of aging and retirement (Minnis, 1988; Schuckit and Miller, 1976). According to A.J. Rosen and M.M. Glatt (1971), retirement ranks higher than bereavement as a precipitating factor in alcohol abuse among older adults. In a similar fashion, heavy drinking and cirrhosis mortality rates increase with unemployment (Brenner, 1975; Barnes and Russell, 1977; Ojesjo, 1980; Jacobson and Lindsay, 1980). M. Seeman, A.Z. Seeman, and A. Budros (1988), however, found that, although high unemployment was associated with greater intake, it was not a significant factor for predicting either increases in the amount of alcohol consumed or drinking problems. Also, Ames and Janes (1987) found that, among the unemployed men in their sample, heavydrinking practices decreased after they were laid off for the simple reason that unemployment separated them from their job-based drinking groups. According to the alienation perspective, work roles that lack creativity, variety, and independent judgment create in workers a sense of dissatisfaction and powerlessness which they learn to relieve through drinking. As J. O'Toole states, alienation produces "a consequent decline in physical and mental health, family stability, community participation and cohesiveness, and balanced political attitudes, while there is an increase in drug and alcohol addiction, aggression and delinquency" (1974; xvi). Job complexity indexes have been used by researchers to operationalize the

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amount of creativity, variety, and judgment in work roles; however, these studies have produced mixed results. B.J. Widick (1976), J.F. Runcie (1980), and R. Hingson, T. Mangione, and J. Barrett (1981) report that boring tasks were significantly and positively related to drinking behavior. Similarly, D.A. Parker and J.A. Brody found that job complexity accounted for "some of the variance in alcohol problems" (1982, 120), although it actually accounted for less than "never married" among women, and the relationship was more pronounced among men than women in the sample. J. Archer (1981) and Seeman and C.S. Anderson (1983), on the other hand, found little support for the hypothesis that either boring work or job complexity is related to drinking behavior. Although T.W. Mangione and R.P. Quinn (1975) found a significant association between drug use and low job satisfaction, most researchers have concluded that "the relationship between job satisfaction and any type of drug use is not a strong association" (Newcomb, 1988, 94). For instance, Archer (1977, 1981) found no differences on job satisfaction indexes between alcoholics and nonalcoholics, and Seeman and Anderson (1983) found no correlation between job satisfaction and drinking behavior. Some researchers (Herrington, Levy, and Reichman, 1980; Hardy and Cull, 1971) even report that alcoholics are more satisfied with their jobs than nonalcoholics. Powerlessness, however, shows a clearer relationship to drinking than job complexity. According to D.C. McClelland and his colleagues, "men drink primarily to feel stronger; those for whom personalized power is a particular concern drink more heavily" (1972, 334-35). M. Levy, F.W. Reichman, and S. Herrington (1979) and D. Castor and O. Parsons (1977) interpreted their data as indicating a general feeling of powerlessness in alcoholics. Similarly, Seeman and Anderson (1983) found that a general sense of powerlessness is consistently associated with heavy and problem drinking and that a high degree of involvement in workplace support networks failed to alleviate the overall sense of powerlessness. In a replication study, Seeman, Seeman, and Budros found that "drinking and its problems are predicted not so much by the degree of network engagement (the sense of 'community' per se) as by the drinking environment— specifically a companionate style of drinking" (1988, 196-97). The work stress perspective focuses upon workplace experiences and events that become translated into life strains; however, unlike the alienation model, the stress perspective does not assume that work roles are central in people's lives and that work in modern society is intrinsically dissatisfying. Conceptually, the work stress and the alienation models are distinct; however, in their operationalization, the two often become blurred (e.g., Seeman and Anderson, 1983; Parker and Brody, 1982). The stress model emphasizes simple empiricism and contains a collection of miscellaneous workplace and nonwork stressors (Holt, 1982, 422), including physical properties of the working environment, changes in job content, machine pacing, monotony, boredom, role conflicts, degrees of control over work processes, work overloads or underloads, inequality of pay,

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and job complexity. Such workplace experiences do not necessarily impact on employees directly, but they may function to intensify other emotional distresses (Pearlin etal., 1981, 340). Empirical research has found that a variety of work stressors are correlated with drinking problems (Hingson, Mangione, and Barrett, 1981; Parker and Brody, 1982). For instance, several studies (Trice and Belasco, 1970; Sherlock, 1967) trace the onset of alcohol and drug problems to the stress associated with career commitments; others link drinking behavior to role ambiguity, role overload, and job insecurity (Margolis, Kroes, and Quinn, 1974; Ferguson, 1974); still others relate it to the stress associated with status inconsistencies (Parker, 1979) and feelings of being left out by technological changes (Trice and Roman, 1971). Apparently, stress at work and drinking are related because workers who feel stressed learn that drinking is an appropriate method for unwinding. For instance, M.L. Fennell, M.B. Rodin, and G.K. Kantor (1981) found that, if employees experienced one of eight different stressors, they were likely to state that a particular reason for drinking (e.g., to relax, to forget) was important. Likewise, Ames and Janes (1987), who did not distinguish between stress and alienation in their study, found that workers reported that one way in which they coped with the boredom on assembly-line work was to drink. Similarly, T.L. Conway and associates (1981) found that naval commanders reported more drinking during low-stress than high-stress weeks. Apparently, they believed that drinking was appropriate away from the base, but they were less likely to leave the base during high-stress weeks than low-stress ones. Similarly, Seeman, Seeman, and Budros (1988) report that recent stress experiences exacerbate the individuals' sense of powerlessness and increase drinking problems; however, the relationship between powerlessness and drinking behavior is moderated by group drinking norms—powerlessness attends a companionate style of drinking, particularly where a respondent matches or exceeds the drinking level norms of his friendship group. Alienation and stress, then, are learned rationales for drinking. Clearly, these preceding streams of relevant research have considerable implications for both worksite intervention and prevention. Despite inadequacies (Googins and Kurtz, 1980; Roman, 1982a), there is a distinct potential for intervention in the constructive confrontation strategy. It is based in the premier institution of American culture, possessing a legitimacy and potency to intervene unmatched by any other basic institution. Practically all developing alcoholics work in a work organization and are subject to its influence. Unfortunately, the alcoholism movement, relatively speaking, has paid only scant attention to this workplace potential. This may be a prominent reason why there has been little aggregate change in the prevalence of alcohol abuse and dependence in America over the past twenty years (Hilton and Clark, 1987). Apparently the volume of drinks consumed over the past twenty years did not change significantly one way or the other, and the proportion of respondents experiencing any of nine problem consequences did not change, but there was a slight increase in the

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proportion who reported experiencing one or more dependence problems. These are sobering facts for activists in the alcoholism movement. They need to reexamine their low priority for workplace intervention. In addition, as we have seen, workplaces appear to contain within them genuine risks for the development of drinking problems. These may well rival those risks that come from genetic influences, from family dynamics, or from social class risks. Indeed, for example, personality risks of alcohol abuse may join job-based risks to precipitate abuse. (For an indepth discussion of job-based risks in relation to other risk sources, see Trice and Sonnenstuhl, 1988b, 1990). In applied terms it seems obvious that a reduction, even elimination, of work-related risks could be an influential prevention measure. Although the quality of research in both of these streams ranges from rather low to reasonably well done, there is, nevertheless, enough information in both to consider them worthy of actual utilization. But there immediately arises the question of how to get them utilized within workplaces. Although widely scattered and unintegrated, there are a number of empirical pieces of discrete research about research utilization in workplaces. When these are juxtaposed to one another, they provide some leads to the nagging, disquieting question of application and use in real workplaces. RESEARCH ON UTILIZATION OF BEHAVIORAL SCIENCE RESEARCH This third stream of research relevant to our overall theme has focused upon the processes by which research about organizational behavior has actually been utilized within work organizations. Researchers in this stream address the question of how to improve the utilization of organizational research, operating on the reasonable assumption that research is largely in vain unless considered, by and somehow actually applied, within the workplace. The research in this stream has uncovered three major types of use: (1) instrumental use, which involves acting on research in specific, direct ways; (2) conceptual use, which involves using research in a less specific, more indirect way than in instrumental use; and (3) symbolic use, which involves using research results to legitimate and sustain predetermined positions—for example, using research results selectively or otherwise distorting them to justify actions taken for other reasons (Beyer and Trice, 1982). Of the three types, conceptual use seems to predominate; symbolic use is a close second. Instrumental use was rare, indeed, in these findings. A prominent feature of this empirical research on research utilization is its findings about establishing links between researchers and user systems (Beyer and Trice, 1982). Some relevant findings for us are as follows: • Users are more apt to use research based on qualitative methods, using variables that are susceptible to change.

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• Researchers are often indifferent about diffusing their results and frequently believe it is improper to purvey their own findings. • Other researchers in this stream use theirfindingsto encourage researchers to become advocates of their own research, thereby gaining the attention of potential worksite users. • Overall, the predominant theory that came from this stream seems to be analogous to supply-side economics: improve the supply of quality information and then assume that demand for it will thereby increase. • The strongest theme that emerges from this stream is that many analysts have called for the development of new roles and occupations to provide linkages between researchers and users. Titles given to this new role vary widely from the questionable one of "social engineer" to "applied social scientist." In other words, the most commonly advocated solutions for bridging the gap are various kinds of linking roles (Likert and Lippitt, 1953; Thompson, 1956; Guetzkow, 1959; Lundberg, 1966; Sundquist, 1978; Rossi, 1980). Although it seems obvious that existing occupations and roles might provide some linkage between EAP researchers and potential organizational users, it seems likely that EAP work is sufficiently unique and distinctive to call for an independent role, i.e., a new linking role. On the other hand, an absorption into human resource management is a distinct option, one that seems to have happened to work in the field of organizational development (Tichy, 1978; Beyer and Trice, 1983). This course may be the inevitable one for EAP work—a cooptation by general personnel work. At the moment, however, it seems more appropriate to examine EAP work as an independent linking role, one with distinctive and unique tasks. One of the early proving grounds for the emergence of a distinctive EAP role occurred in 1972 when the National Institute on Alcohol Abuse and Alcoholism offered funding ($50,000 per year for three years, plus opportunities for renewal) to all the states to support a new role in job-based alcoholism programs. Two persons could be hired in each state to function as occupational program consultants (OPCs). Their basic task would be to persuade decision-makers among employers and unions—in both public and private sectors—to adopt and implement job-based alcoholism policies (Roman and Trice, 1976). In effect, the OPCs were to be the sowers of seeds from which new job-based programs were expected to grow. Based outside specific workplaces in community agencies, the OPCs were essentially outside change agents whose job it was to persuade, influence, and assist employers and unions throughout the state to adopt and implement EAP programs. Trice, Beyer, and C. Coppess (1981) reported a study of the OPC network in New York State (which had an average of 15 OPCs in the field in 1976) and how employers and unions reacted to the consultants. Among the prominent characteristics of successful OPCs "was their possession of work-world experiences and backgrounds that backed up the training they had received on alcoholism and job based programs . . . the responsive organizations perceived the

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OPC as both competent and empathetic, displaying technical knowledge in personnel administration and labor relations, and showing a capacity to work well with the internal problems of managing change" (1981, 328, 330). In addition, if users initially viewed the program as easy to administer, as a mechanism that would improve supervisory performance, they were more likely to take steps to adopt and implement it. In sum, the successful OPC was one who first and foremost understood the workplace and how to work within its dynamics. These findings seem applicable to the EAP worker. To play an effective linking role, he or she must have a keen sense of how work organizations behave, and how to perform within that context. Justification for careful consideration of linking roles as mechanisms for utilization—especially conceptual use—comes from the most persistent observation in all the literature on the subject, namely, that researchers and users belong to separate subcultural communities with very different values and ideologies that impede utilization (Dunnette and Brown, 1968; Glaser and Taylor, 1973; Rothman, 1980). For example, the abstract terminology and methods used by researchers are symbolic of the gaps between the two cultures (Van de Vail, Bolas, and King, 1976). Consequently, managers, occupational peers, and union officers tend to assume that the constructive intervention strategy is difficult to implement and that it requires a professional who can take the alcoholic or troubled employee off their hands (Trice and Beyer, 1984b). What is required for a smooth translation from research to application is a linking role: someone who can bridge the cultural gap by maintaining an inbetween role and holding values and beliefs somewhere in the middle (Beyer and Trice, 1983; Guetzkow, 1959; Lundberg, 1966; Rossi, 1980). Currently, such a linking role is evolving in the workplace: the employee assistance program worker (Blum, Roman, and Tootle, 1988; Blum, 1988; Roman and Blum, 1988), who acts as a consultant and helper for workplaces, activates the use of the constructive confrontation strategy, and informs managers and union officers at all levels about risk factors and how they might be attenuated. A tradition has begun to form among EAP workers that they are not the actual interveners, not the source of norms. Rather, they encourage and facilitate the formation of interventions within the structures and subcultures of workplaces, that it is the workplace itself, not a handful of specialists, from which effective actions come. For example, Roman and Blum (1988) list as the first three items of the core technology of EAP work tasks that are specifically directed at aiding workplace personnel to activate prescriptive norms: (1) identification of employees' behavioral problems based on job performance issues; (2) provision of expert consultation to supervisors, managers, and union stewards on how to take the appropriate steps in utilizing employee assistance policy and procedures; and (3) advice on the availability and appropriate use of constructive confrontation. The EAP role is still emerging; consequently, university courses for teaching workers how to implement it are relatively recent (Quick, Sonnenstuhl, and Trice, 1987). At Cornell we have recently been conducting research on such a potential

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linking role relative to research findings about the role of workplaces in prevention and intervention. Generically calling these roles "EAP workers," we have asked the question: How does the role, as an emergent occupation, come into existence? We have conceptualized the EAP worker as a potential link between accumulated relevant research, such as just described, and potential users in the workplace: managers, occupational peers, union officials, and medical and personnel staff. We have visualized one of the basic tasks of EAP workers as providing expert consultation to these functionaries on how the workplace can make a positive contribution to prevention and to active intervention. That is, we have embarked on an educational program to educate EAP workers about the core tasks of their emerging occupation. For the past three years, we have offered in New York State's larger cities a one-and-one-half-year educational program—in the full sense of the word—for EAP workers. It provides 18 hours of Cornell credit, has all the features of typical upper-class undergraduate courses, and is based on credit courses offered on the Cornell campus. The only difference is that those in our continuing education centers use only EAP-related materials for the instances of application for the principles in the courses. Primarily, these courses enlarge and refine upon the core tasks performed in EAP work. As a consequence, we have focused our research on what effects our education has had on their acceptance and practice of the core tasks. In short, have they become a potential linking role between research findings about workplace intervention and prevention, on the one hand, and workplace users on the other? We conducted the education in Syracuse, New York City, Albany, and Rochester, and we are currently under way in Buffalo and Westchester. We have collected qualitative data on the research question using the constant comparative method (Glaser and Strauss, 1967) to analyze, on a highly preliminary basis, data from classes in two sites: Syracuse and New York City, including 61 students who have finished the entire one-and-one-half-year program. Preliminary hunches that come from the analysis suggest three kinds of responses to the EAP educational experience:1 • Cooptation: In this mode, students essentially rejected the core tasks of EAP work and continued to see EAP work as they had conceived it before they entered the program. Example: Clinical occupations. • Accommodation mode: In this mode, students accepted the core tasks and found them to be compatible with their earlier notions about what EAP work actually was. Example: A As in EAP work. • Assimilation mode: In this mode, the students enthusiastically embraced the core tasks. They strongly supported balanced programs, those that incorporated both workplace and treatment place in EAP work. Example: Newcomers and those not currently employed as EAP workers. Should these findings hold up—and that is problematic—conceptual usage of prevention and intervention findings might well be facilitated via the EAP work-

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er's emerging occupation. Research by Blum (1988) and by Blum, Roman, and Tootle (1988) supports the notion that a new occupation of EAP work is, in fact, emerging. The findings reported here, although far from complete and highly tentative, do suggest that a linking role may be in its formative stages. It is worth noting that two of the three kinds of reactions to our EAP education program (accommodation mode and assimilation mode) were characterized by an acceptance of the linking tasks in the EAP role. If the EAP movement can embrace a policy that encourages and insists upon a substantial education that includes the bodies of knowledge reviewed here, there is a clear chance that the potential of the worksite can be truly realized. NOTES I gratefully acknowledge the Christopher D. Smithers Foundation for support in preparing this manuscript. 1. I am indebted to William Sonnenstuhl and Laurie Roemmele for helping me with this exploratory and tentative analysis. Also see Sonnenstuhl, Trice, and Roemmele (1988). REFERENCES Akers, R.L., Krohn, M.D., Lanza-Kaduce, L., and Radosevich, M. (1979). Social learning and deviant behavior: A special test of a general theory. American Sociological Review, 44, 636-655. Ames, G.M., and Janes, C.R. (1987). Heavy and problem drinking in an American bluecollar population: Implications for prevention. Social Science and Medicine, 25 (8), 949-960. Applebaum, H.A. (1984). Work in market and industrial societies. Albany: State University of New York Press. Archer, J. (1977). Social stability, work force behavior, and job satisfaction of alcoholic and nonalcoholic blue-collar workers. In C. Schramm (Ed.), Alcoholism and its treatment in industry. Baltimore: Johns Hopkins University Press. Archer, J. (1981). Alcoholism and alienation among blue-collar workers: Test of a causal theory. Unpublished doctoral dissertation, Johns Hopkins University, Baltimore, MD. Barnes, G.M., and Russell, M. (1977). Drinking patterns among adults in New York State: A descriptive analysis of the sociodemographic correlates of drinking. Buffalo, NY: Research Institute on Alcoholism. Beyer, J.M., and Trice, H.M. (1978). Implementing change: Alcoholism programs in work organizations. New York: The Free Press. Beyer, J.M., and Trice, H.M. (1982). The utilization process: A conceptual framework and empirical findings. Administrative Science Quarterly, 27, 591-622. Beyer, J.M., and Trice, H.M. (1983). Current and prospective roles for linking organizational researchers and users. In R.H. Kilman, K.W. Thomas, D.P. Slevin, R. Nath, and S.L. Jerrell (Eds.), Producing useful knowledge for organizations (pp. 675-702). New York: Praeger. Beyer, J.M., and Trice, H.M. (1984). A field study of the use and perceived effects of

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23 PREVENTION OF ALCOHOL PROBLEMS IN THE WORKPLACE: A PUBLIC POLICY PERSPECTIVE HAROLD D. HOLDER

The greatest historical emphases on alcohol problems at the worksite have focused on the employee assistance programs (EAPs) and employer policies concerning problem-drinking employees. This emphasis has stimulated the growth and acceptance of EAPs as a positive response to individual employees with drinking problems which affect their work performance, families, and social situations. Employers are now more willing than ever to keep problem-drinking employees if constructive efforts to receive treatment and demonstrate recovery are under way. The challenge to us is how to build upon this positive base to consider strategies for prevention in the workplace which address not only individually impaired employees but alcohol-related problems in general. Therefore, we are challenged to find ways to complement the identification, referral, and treatment strategy. Such complements include strategies that address alcohol misuse not only before chronic individual problems begin but which also address other alcohol-related problems not necessarily caused by alcoholics and chronic problem drinkers. We would benefit in this search from an examination of potential applications from other areas of prevention program, policy, and research. ALCOHOL PROBLEMS IN THE WORKPLACE The essential first question for prevention in the workplace is "what do we wish to prevent?" Workplace intervention to date has focused largely on individual workers who are having personal difficulty with alcohol. This difficulty is often manifested at work by absences, tardiness, lowered work performance, or even accidents. These problem drinkers may be identified (either by supervisors or by the employees themselves), clinically diagnosed as alcoholics, and

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enter treatment. Research has shown that both they and their families are higher consumers of general health care and, therefore, incur a greater than average cost to the employer's health care expenditures either through higher insurance premiums or direct expenditures (if self-insured). (See Holder and Blose, 1987; Holder and Hallan, 1986.) Intervention at the individual problem drinker or alcoholic level at the workplace is important, but it does not address the larger set of alcohol-involved problems to both the workplace and the larger community. A goal for workplace prevention of alcohol-involved problems broadens our emphasis to the entire workplace not only to the individual drinker alone. Although we lack the type of epidemiological data that exists for community-level alcohol problems, such as the extent of alcohol involvement in traffic crashes and fatalities (U.S. Department of Health and Human Services, 1987) or emergency room admissions (Cherpitel, in press), there is no reason to believe that the workplace is an exception. Alcohol problems at the workplace are much greater than just those that result from a few chronic problem drinkers. (See Holder, 1987; Moore and Gerstein, 1981.) Alcohol-involved problems at the workplace may include the following concerns: 1. Overall lowered production and performance as a result of on-the-job drinking or heavy drinking before beginning work as well as chronic dependent drinking 2. Lost wages and lowered earnings resulting from absences related to drinking 3. Increased health care costs as a result of drinking, such as accidents and injuries both in the home and in the general community or family violence related to drinking 4. Workplace disruptions including worker conflict or dissatisfaction as well as work accidents and injuries

By using a problem perspective rather than an individual problem drinker or alcoholic employee perspective, prevention goals can be established in terms of reductions in identified problems of direct or indirect concern to the workplace. Strategies for intervention can thus include individual interventions such as those currently being performed by employee assistance programs but also system interventions which might address on-the-job drinking, the physical and social environment of the workplace, or even the larger community. NEED FOR SYSTEMS APPROACHES Our current emphases on problem-drinking employees is in common with some aspects of prevention programming, i.e., changing the individual and his or her drinking pattern. There is a long history in prevention programs of using information and education to alter people's drinking behavior as a means to reduce consumption levels, particularly heavy consumption. More recently, ed-

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ucational strategies have also targeted high-volume consumption, particularly around drinking and driving. Although, in general, educational strategies focused on individual behavioral changes are judged not to be harmful and have the potential to change personal information and sometimes attitudes, they have not shown the ability to change long-term drinking patterns or high-volume, high-risk drinking. Educational campaigns can, however, make a solid contribution to the increase of public support and the acceptance of other prevention programs and strategies. One of the major limitations of a single application of an individual strategy for prevention at the workplace would be a failure to recognize the larger physical, social, and economic system in which drinking can become a part. In addition, the workplace is part of a larger community system which can both encourage and discourage the use and misuse of alcohol at and in conjunction with the workplace. Within this systems perspective, we become interested in the total system of which the individual drinker is a part, including the social and cultural groups both on and off the job, the values and norms of these groups about drinking as well as their actual pattern of drinking, the role of the family, the physical and economic accessibility of alcohol both at the workplace and in the community in general, and the ability of workers to purchase alcohol, i.e., their disposable income.

THE LARGER COMMUNITY SYSTEM OF WHICH THE WORKPLACE IS A PART The community is a complex and dynamic system. The system is complex because it is composed of multiple factors and their interrelationships. It is dynamic because it changes over time. (See Holder and Blose, 1987; Holder and Wallack, 1986.) A community system of alcohol use and misuse is concerned with the relationships between consumption and patterns of drinking (including drunkenness and abstinence). The system also contains formal regulation of and actual availability of alcoholic beverages, community norms, and values about the acceptable and unacceptable uses of alcohol; the legal responses to alcohol-related problems, such as public intoxication and drinking while driving; mortality and morbidity; family and employment problems related to alcohol misuse; the demand for health and social services, including treatment for alcoholism; and such economic factors as disposable income, beverage prices, and tax revenues derived from beverage sales. The community system can be divided into sectors or subsystems. Each subsystem is a grouping of factors, elements, and variables which interact more regularly than the variables, elements, and factors in other sectors. The use of alcohol is the central subsystem; it both affects and is affected by

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other subsystems. The number of drinkers and the average quantity and frequency of consumption (as well as the amount per occasion) are functions of the aggregate drinking patterns of community members. Differences result from gender, age, marital status, and religious preferences. Community consumption is also related to community norms, formal education about alcohol use, the promotion and marketing of beverages, economic conditions, and the amount and effectiveness of alcoholism treatment. The number of eligible drinkers in the community are those members who, based on the minimum purchase age, can legally obtain alcohol. As the minimum purchase age is lowered, the number of potential drinkers increases, and consumption by previously ineligible consumers may also increase. Alcoholic beverages are produced by profit-making companies that seek to increase sales. Each company invests in the promotion of its brands to persuade individuals to use its products. In those countries where production can be privately owned, the profit motive stimulates the industry (based on forecasts of potential sales, costs to produce, and potential profit) to invest in capital equipment and buildings, promotion, and advertising. The costs to produce the product are a function of capital investment, the cost of raw materials, and the operating expenses including plant maintenance. The level of alcohol production is related to production cost and expected sales of distillers, brewers, and wineries. The amount and type of promotion and advertising by the alcohol industry are related not only to the cost of advertising but also to any regulation and restrictions on alcohol beverage advertising. Consumer demand for alcoholic beverages and the availability of alcoholic beverages make up the distribution and sales subsystem in our model. The price of a product relative to the price of other goods and services has been shown to be a powerful ingredient in consumer purchases. Formal regulation is a subsystem concerned with the control of the availability of alcohol. Throughout the world federal or national governments regulate production and add taxes; in the United States, the states also add their own taxes and establish the methods of retail distribution, hours of sales, licensing of outlets, and minimum age of purchase. Alcohol beverage availability depends upon the number and types of outlets for retail sale. Private and legal production as well as illicit supply of alcohol can affect total consumption. Illicit supply is a function of demand for illicit, untaxed alcohol; it is also related to the level of law enforcement and the cost of raw materials for production. The consequences of alcohol use and misuse to the community can be grouped into four interrelated subsystems: (1) legal responses to alcohol misuse, including public intoxication and drunken driving; (2) mortality and morbidity, including early death and injuries from alcohol-related traffic crashes as well as from alcohol-related nontraffic accidents and drinking-related assaults and violence; (3) the social and economic consequences, including family disruptions, work absences, and lowered work performance; and (4) the demand for social and

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health services for alcohol-related trauma as well as for rehabilitative services, e.g., alcoholism treatment and family services. Alcohol-related problems are reflected in arrests for public intoxication and drunken driving, inpatient admissions for detoxification, emergency room treatment of injuries and trauma resulting from alcohol-impaired behavior and assaults, crime related to drinking, and arrests for drunken and impaired driving. The incidence of such events is a function of community consumption as well as community response to alcohol use and what is considered "misuse." Law enforcement for public intoxication and drunken driving depends upon community pressures to take action versus competing pressures concerning other crimes such as assault and burglary. Community concern about alcoholism stimulates the levels of available funds for detoxification and treatment which, coupled with court-required treatment or education, stimulates the availability of both public and private rehabilitative services. Community concern can also stimulate increased formal regulation of alcohol and zoning restrictions on beverage outlets. THE WORKPLACE The workplace is a significant subsystem in a community system; the workplace is affected by and in turn has a significant effect on the total community. The workplace is an essential contributor to economic vitality (or lack thereof) for the total community. If work performance is impaired by drinking, not only is the worksite affected but also the entire community. In this systems perspective, worksite alcohol problems are actually community problems. However, indicators of such problems are not commonly maintained by community agencies, unless workers and their families become clients of social or health agencies. A recognition of alcohol-involved problems at the worksite is not simple or obvious. For within this perspective the prevention of alcohol problems at the worksite becomes the concern of all community members, not just the concern of the employer and the union. THE WORKSITE AS A SYSTEM ITSELF The worksite, while a part of the total community system, is also a system itself. During work, many aspects of the larger community system exist within the workplace including social and economic activities. There are cultural aspects of the worksite which may reinforce or discourage alcohol use and alcohol misuse. There may be aspects of the physical environment which facilitate onthe-job drinking or the desire to self-medicate through the use of alcohol if the job conditions are undesirable.

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Within the workplace, working groups and social attachments which can encourage drinking do exist. These groups can support heavy consumption after work and establish or reinforce patterns of heavy consumption. The vulnerable individual drinker can find himself or herself in social networks at the worksite which encourage (rather than discourage) drinking. BENEFITS OF A SYSTEMS PERSPECTIVE TO PREVENTION To call alcohol problems products of systems rather than individual problems represents a radical departure from past thought in the twentieth century. The implications are profound. Causes are multiple; there is no single best approach. Because problems are inextricably linked to their context, it is necessary to understand the context in order to understand the problem. Values, being an important part of the context, must be explicitly recognized. A systems approach to preventing alcohol-related problems does not replace past efforts. Rather, this approach incorporates other strategies and broadens them. Its comprehensiveness includes rather than eliminates other approaches. The implications of a systems approach to worksite prevention are significant. Long-term planning is emphasized rather than short-term problem solving. The goal is to strive for consistency of purpose across all levels on which the problem exists. Although the search for a single necessary and sufficient cause of alcohol problems with individuals continues, we should now understand that such research addresses only a relatively small part of the total problem. Because alcohol-related problems are linked to broad social, political, and economic forces, such problems cannot be understood, much less solved, without focusing attention on these forces. Adopting the systems perspective on drinking and alcohol problems would require changes in the way we approach prevention and additions to the way in which we undertake research. Most important, the systems approach would require us to broaden our primary emphasis on the identification and treatment of individual problem drinkers. To approach the prevention of problems associated with alcoholic beverages as part of a system is consistent with our understanding of how things work in the world. With this perspective, it becomes possible to identify those social, economic, and psychological factors in the community and in the workplace that we can realistically affect with prevention strategies and to identify the factors outside our influence or control. In this way, we increase the likelihood that prevention will succeed. The prevention of alcohol-related problems operates in a social and economic system where many variables interact over time. Consequently, even if research data increase, we will be limited in applying such data to better prevention activities unless we have a framework to link things together, i.e., to better understand the system. Prevention strategy must be future and action oriented,

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and it must recognize the dynamic interaction of complex social, economic, and political forces.

BENEFITS OF A SYSTEMS PERSPECTIVE TO WORKSITE PREVENTION The workplace as a part of the total community can also benefit from a systems approach to prevention. This perspective emphasizes the total workplace as a system and not just the vulnerability of a few members of this system. The systems perspective enhances current efforts toward early identification of employee problem drinkers. It can also extend our prevention from a few select individuals to all workers. Each worker participates in and helps to shape the system. Each has some responsibility for its positive and negative aspects. By emphasizing the total system of the workplace, we increase our opportunities for prevention and reduction of alcohol-related problems, particularly among workers who may not be chronic problem drinkers. In this way our energy is used to identify and potentially correct those factors that cause or contribute to alcohol problems. We are also able to better understand the very real interaction (interdependency of the workplace) and the larger social, cultural, and economic environment of the community system. For example, the proximity and density of alcohol outlets, both on- and off-premise sales, to the worksite may enhance existing tendencies for heavy consumption, both during and after work. The supportive role of the worker's family and family activities (including the role of drinking within family life) can contribute to constructive or destructive use of alcohol in conjunction with the worksite by workers. The policy of the employer concerning alcohol use and alcohol-involved problems and the consistency of application of policy is likely a significant contributing factor in the workplace system. The role and attitudes of the union about drinking in general and drinking in conjunction with work can be potential preventive or potential dysfunctional factors.

OBSERVATIONS FROM OTHER PREVENTION EFFORTS AND POLICIES Although our documented successes in reducing alcohol problems are limited (there are certainly more failures than successes), some things can be learned from the general area of alcohol prevention. • Environmental strategies which recognize drinking norms and drinking contexts have shown greater potential to reduce alcohol problems, particularly high-risk drinking, than educational strategies.

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• Alcohol problems and alcohol availability are not independent. Restrictions of the availability of alcohol in the worksite and efforts to reduce its easy availability can be effective strategies. Restrictions on increased accessibility and availability in the general community could suggest strategies for the worksite. • Mixed prevention strategies, for example, public education coupled with legal changes, have greater potential to reduce problems than single strategies. • An understanding of the total community system of alcohol use and misuse in which the workplace exists would facilitate the development of effective prevention strategies for the workplace itself. • A partnership between the employer and employee organizations with the other parts of the community system to reduce alcohol problems would benefit both the workplace and the total community. • The economic aspect of alcohol use should be a central consideration in developing prevention strategies. Alcohol use and problem use, even among young people, has been shown to be price sensitive. A discussion of how alcohol price strategies can be part of a workplace prevention strategy is beyond this discussion, but the potential roles of income and price are important. For example, if price promotions for on-premise consumption occur in establishments in proximity to the worksite, these price promotions could contribute to overall levels of consumption and to heavy, high-risk consumption. • There is good evidence that the drinking context can contribute to heavy and high-risk consumption. For example, it is known that a majority of drivers with nonzero blood alcohol levels on the road during normal nonworking hours are coming from on-premise outlets including bars, taverns, and restaurants. The drinking context of workers, particularly immediately after work, can positively or negatively contribute to alcohol misuse. While the employer or the employee unions may not be able to directly affect high-risk drinking establishments (perhaps they can with friendly arm twisting), a concern for the drinking context could be a part of a comprehensive assessment of alternative prevention strategies. • Although it has not been reliably evaluated as a means to reduce alcohol misuse, health promotion at the workplace can emphasize positive ("feel better") strategies rather than negative ("avoid problems") strategies. As others have observed, the workplace is a natural environment for the promotion of a healthy lifestyle, including smoking cessation and reduction of personal drinking. Both the employer and employee have investments in improved worker health.

CONCLUSIONS Both traditional EAP researchers and prevention researchers have much to gain from collaborative study on worksite prevention. Prevention researchers have not had a tradition of looking at the worksite as a point of prevention. Rather, we have considered how community system prevention strategies may reduce alcohol-related problems at work. This volume offers a forum to explore potential ways to learn from each other. Potential areas of common research interest include:

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1. The role of drinking subgroups on alcohol and drug use in and in conjunction with the worksite. 2. The relationship of employer policies concerning alcohol availability at the worksite to alcohol-related problems. 3. Epidemiological studies both to improve the accuracy of our estimates of alcoholinvolved problems, as well as over time indications of incidence. For example, to know the distribution of blood-alcohol-levels of workers and injuries on the job in the same way we know these levels for traffic safety. 4. Participation of researchers in the planning and development prevention strategies for the workplace not only to design evaluation but to contribute the knowledge and experience of researchers to such development. 5. Studies of the workplace as a social, cultural, and economic system with its own unique physical environment. 6. Studies of natural experiments in which changes in the workplace (for other than prevention purposes) can affect alcohol use and alcohol-related problems. 7. Examination of the EAP as a potential system change agent to stimulate preventive approaches to the workplace as a complement to early identification and referral to rehabilitation activities. NOTE Support from Grant No. P50-AA-06282 from the National Institute on Alcohol Abuse and Alcoholism is gratefully acknowledged.

REFERENCES Cherpitel, C.S. (in press). Alcohol consumption and casualties: A comparison of two emergency room populations. British Journal of Addiction. Holder, H.D. (Ed.). (1987). Control issues in alcohol abuse prevention: Strategies for states and communities. Greenwich, CT: JAI Press. Holder, H.D., and Blose, J.O. (1987). The reduction of community alcohol problems: Computer simulation experiments in three counties. Journal of Studies on Alcohol, 48(2), 124-135. Holder, H.D., and Hallan, Jerome B. (1986). Impact of alcoholism treatment on total health care cost: A six-year study. Advances in Alcohol and Substance Abuse, 6 (1), 1-15. Holder, H.D., and Wallack, L. (1986). Contemporary perspective for the prevention of alcohol problems: An empirically-derived model. Journal of Public Health Policy, 7(3), 324-339. Moore, M.H., and Gerstein, D.R. (Eds.). (1981). Alcohol and public policy: Beyond the shadow of prohibition. Washington, DC: National Academy Press. U.S. Department of Health and Human Services. (1987). Sixth special report to the U.S. Congress on alcohol and health (DHHS Pub. No. ADM 98-1519). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

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24 STRATEGIC CONSIDERATIONS IN DESIGNING INTERVENTIONS TO DEAL WITH ALCOHOL PROBLEMS IN THE WORKPLACE PAUL M. ROMAN

THE IMPORTANCE OF STRATEGIC PLANNING Readers of this book should be left with little doubt about the multifaceted considerations that may be involved in effectively addressing alcohol problems in the workplace. But there is also little doubt about the interest and concern on the part of workplace leadership in confronting alcohol-related issues among employees. From the materials presented in the book, it is clear that there is no simple set of solutions or an ideal approach that fits every workplace. This concluding chapter highlights a number of themes that run across several chapters and offers observations and suggestions that pivot from these themes. The observations and suggestions bear upon strategic decision-making in organizations. This general concept refers to planning that centers around clearly stated organizational goals. Recently there has been increased attention given to incorporating human resource management issues into strategic planning. All too often human resources management operates in isolation from other organizational functions. Most explanations for such isolation center on the minimal priority that historically has been accorded to human resources policies and their implementation in the American workplace. Recognition of the relative importance of managing human resources is, however, undergoing dramatic changes at present, driven by current and anticipated social changes. These include: 1. Recognition of the changing demography of the work force (pointing toward definite shortages of needed skills in practically all sectors of the economy) as we move toward the twenty-first century. 2. The changing nature of the relationship between workers and technology, affecting the organization, design, timing, and flow of work.

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3. The institutionalization of labor force participation by the majority of women in American society. This is one of several forces contributing to the increasing interpenetration of employees' family and personal commitments into the flow of day-today work as well as into the patterning of long-term employee careers. On the face of it, employee alcohol problems seem quite "distant" from the primary goals and future plans of most organizations. This is true if one leaves human resources out of the critical dimensions of planning. However, it is becoming more common to include human resource factors in business planning. There are multiple dimensions of the impact of employees' problem drinking behaviors on workplaces if they are not dealt with seriously and systematically. Beyond the fact of the universal presence of employee alcohol problems at some time in every workplace, there are two specific projections that call particularly for employer attention to employee alcohol problems: 1. The federally sponsored "war on drugs" may be providing indirect encouragement for the use of alcohol as the primary drug of choice among those who might otherwise use other substances. This encouragement may occur through the war's intense emphasis on excluding users of illegal drugs from the workforce and on taking adverse actions toward employed persons who are found to be users of illegal drugs. To an extent, the occurrence of extreme reactions toward illegal drugs increases the cultural support and legitimacy of alcohol use in a societal context where alcohol is legal and universally available. Relevant to possible workplace impact are longitudinal data collected in the early 1980s in large samples of the U.S. military. These data indicated significant increases in alcohol use and reported alcohol problems following worldwide "crackdowns" on the use of illegal drugs (Bray et al., 1983, 1986). Thus it is not unreasonable to expect increased alcohol usage among U.S. workers in the 1990s, particularly in those cohorts that at an earlier age might have been prone to the recreational use of illegal drugs, a behavior pattern that now threatens individuals' employment and livelihoods. 2. Because of the aging of the work force, it is very possible that workplace alcohol problems in the mid-1990s may far outrun current rates. Rates of individual alcohol problems tend to peak during the middle years, between the late 30s and the late 40s (Pattison and Kaufman, 1982). This does not necessarily mean that at these ages individuals are showing their highest lifetime levels of alcohol consumption. Instead it indicates that after reaching this age range, people are more likely to manifest disruption of role performance and evidence of loss of control over drinking patterns than at earlier ages. Drinking patterns change during this decade of life through the adoption of abstinence, reduction of drinking, or death associated with drinking consequences. This means that initial manifestations of severe drinking problems after the age of 50 are also lessened. Thus the occurrence and distribution of alcohol problems are related to the numerical size of different age segments of the population (Pattison and Kaufman, 1982). In the 1990s the bulk of the Baby Boom generation will be passing

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through the age levels that historically have shown the greatest development of alcohol problems (National Institute on Alcohol Abuse and Alcoholism, 1990). In terms of sheer numbers, this decade is expected by far to experience the greatest number of adult alcohol problems. These epidemiological projections highlight substantial disruptions in the workplace, especially when coupled with other expected changes. Given these projections of increased employee alcohol problems, there is no doubt that employers can anticipate and curb future costs impacts by planning and preparation. There is not a single design or solution for approaching employee alcohol problems that fits all workplaces equally well. An excellent starting point for any workplace in dealing with this complex of issues is to view these problems within a strategic human resources management plan, which in turn must be built upon the workplace's broader long-term strategic plans. In the following sections issues in designing alcohol-related programming are reviewed. These points are directed toward workplace decisionmakers in two categories: (1) those who have already taken steps to deal with employee alcohol problems and who desire to maximize the outcomes associated with the investments that have been made or will be made in the future, and (2) those who are at some phase of the decision-making process in establishing systematic efforts to deal with alcohol problems in their respective workplaces. The following discussion draws upon the materials in this book but is not intended to repeat or summarize them. This chapter draws upon my own research, observations, conclusions, and "studied opinions" regarding alcohol and workplace issues that have accumulated over the past 20 years. From this vantage point, and from many of the materials presented in this book, employee assistance programs (EAPs) clearly stand out as the most commonly adopted solution to dealing with employee alcohol problems. Indeed the bulk of the research that I and my collaborators have conducted has focused on EAPs. The evidence for the value of EAPs is strong. Particular attention is drawn to a recent benefit impact study at McDonnell-Douglas Corporation, which practically compels the attention of organizational decisionmakers who have not yet taken seriously the implementation of an EAP. But to argue that EAPs are the best solution or to singularly advocate "EAP orthodoxy" is far too narrow a stance. Such a position does not fit with the facts that there are many considerations that go well beyond the current design of most EAPs. Some of the authors of the preceding chapters may be more orthodox than I am. Thus some of my notions presented here may distinctively contradict some of the assertions of several of them. THE WORKSITE AS A SETTING AND A SOURCE OF EMPLOYEE ALCOHOL PROBLEMS There is little argument that practically every workplace is faced with some level of employee alcohol problems. Thus when this issue is raised, the passive

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"solution" for a workplace to "do nothing" is not reasonable, given any degree of acceptance of contemporary principles of management. Regardless of the apparent presence or distribution of alcohol problems at one point in time, it is evident that policy-based preparation for dealing with such problems cannot be viewed as a "luxury." Indeed this kind of preparation is viewed as a "basic" by employers who are attuned to the costs of production disruptions as well as to containing costs associated with human resources management. There is a parallel between policy readiness for dealing with employee alcohol problems and policies designed to ensure workplace safety. Safety policies are designed to prevent suffering, losses, and disruptions. It would hardly be suggested that safety policies and programs should be implemented only after numbers of serious accidents and losses became evident. At the same time, the content of a particular safety policy/program is based upon the experiences and environmental assessments associated with a particular workplace. Also, by the same token, the disruptive impacts and various workplace "costs" produced by employees with alcohol problems can vary greatly from case to case and from setting to setting. These effects depend on the employment circumstances and the timing and manner in which events and cases are handled. Because of this variability in impact and the basic impracticality of attempting to quantify behaviors that by their very nature are largely hidden, surveys or other efforts to generate "case counts" may be misleading as a basis for "needs assessment." Evidence from employers' experiences to date indicates that every workplace can increase its operative efficiency by introducing and supporting systematic measures to deal with employee alcohol problems. Given the difficulties associated with valid measures of problem prevalence, however, a "needs assessment" should emerge from the usage data associated with a programmatic intervention, with resources subsequently adjusted on the basis of this evidence. The design of an intervention can be more practically based on fitting such interventions with structure and process in the flow of work and in relationships among workers in particular workplaces. Such design can also benefit from the experiences of other workplaces that is documented through research.

SCREENING AND PARALLEL MEANS OF DETECTION To begin to examine alternative strategies, what might appeal to some proudly hard-headed managers would be the straightforward and pragmatic solution of finding employees with alcohol problems as quickly as possible and removing them from the workplace. Despite the simplicity of such a policy, it is indeed difficult today to find many workplace leaders who accept a "find 'em and fire 'em" solution to dealing with employee alcohol problems. Such an idea is usually dismissed because of the multiple legal protections and requirements for due process that surround

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employment contracts for both unionized and nonunionized employees in practically all work settings. But of greater significance is the fact that most managers recognize (1) the value of their investments in trained employees, (2) the costs of employee turnover, replacement, retraining, and reintegration, and (3) the impact on workplace morale of an atmosphere characterized by witch hunting and arbitrary control. Independent of legal considerations, there is wisdom in efforts to salvage human resources prior to dismissal and replacement. It is this type of thinking that reflects the "sense" of strategic planning. What about random screening of current employees for evidence of alcohol abuse? Even aside from practical considerations of its impact on employee morale and loyalty, such a singular strategy is rendered less than effective by the relatively rapid metabolism of alcohol from the human body. Testing for the presence of alcohol in the blood or breath is limited to detection of recent drinking events. Thus the potential effectiveness of such a strategy is undermined by the fact that the impact on the workplace of many if not most employees' problem drinking stems from off-the-job drinking, which is beyond the employer's control. Drinking in off-hours may result in full or partial absenteeism from work. Off-job drinking probably has one of its greatest impacts on the job through the hangover, which occurs after sobriety and when blood/breath detection of drinking would be considerably less likely, using commonly available technology. These critical observations by no means suggest that employers should abandon fitness-for-duty or other rules that proscribe drinking in conjunction with work and that afford physical examination of those who are suspected of such behavior. From my perspective, fitness-for-duty policies that prescribe penalties for drinking or intoxication during work hours set a firm foundation for any type of constructive intervention that the workplace might introduce. Such a policy can communicate to all levels of an organization that it is primarily concerned with job performance. Such communication provides a context for both managers' and employees' interpretation of the organizational motives that underlie other policies, minimizing the impression that they have been introduced as new employee benefits, social welfare efforts, or "Big Brother"-style intrusions into the private lives of workers. Fitness-for-duty policies can, however, create a false sense of security about organizational policy to deal with employee alcohol problems. It must be clear that fitness-for-duty policies and accompanying on-the-job screening for evidence of recent drinking are partial solutions at best and will most likely identify only a tiny proportion of the problem drinkers. Thus something other than a "weedingout" system directed toward current employees is typically called for. Before leaving this level of defining problem solutions, what about preemployment screening for alcohol problems? Such a stratagem could conceivably substitute for the necessity of dealing with employed alcohol abusers. Pre-employment screening for the use of illegal drugs through the testing of urine samples has been widely and rapidly adopted (Blum and Roman, 1989).

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Motives for adopting this type of drug screening are a combination of a desire to reduce future drug abuse problems in the workplace and a desire to avoid hiring those whose behaviors indicate a willingness to engage in illegal acts. The massive publicity and attention that have been created by the adoption of preemployment drug screening may offer another source of a false sense of security to employers who use such screens. Unfortunately those who market drug screening services rarely inform employers that alcohol problems in the work force outrun illegal drug use at a geometric rate. Further, it is often assumed that these urine-based screens identify drug problems or drug abuse. In fact, urine-based drug screening technology is limited to detecting evidence of some form of recent use of specific substances. Marijuana use is the category most often detected (Guste and Walsh, 1989). Many would question whether evidence of marijuana use is a reasonable indicator of a drug abuse problem. Finally, it must be kept in mind that residues of this drug remain in human tissues for lengthy periods such that a positive drug screen does not necessarily indicate recent use. Independent of these problems, the fact is that there is no parallel to illegal drug screening for the identification of alcohol problems at the time of employment. Even though blood alcohol level could be obtained from applicants during employment interviews, all of the problems associated with screening current employees for alcohol problems affect the utility of pre-employment screening. Even if a good screen for alcohol use could be developed that parallels the currently used screens for illegal drugs, there are major drawbacks. Remember that marijuana, cocaine, and opiates are illegal drugs. Any evidence of their use may be determined by the employer to constitute an adequate reason for excluding an applicant, that is, the individual has engaged in an illegal act. Alcohol, by contrast, is a legal drug. A screening device that produces evidence of its use during the days prior to the employment screen does not suggest criminality but rather may even suggest normality. Thus there is a degree of irony in that the apparent technological success of screening devices has been limited to categories of behavior that characterize a tiny proportion of the active or prospective work force. These devices have little or no relevance to abusive use of alcohol, which is a major work-force problem and very resistant to identification. Many questions have been raised about the effectiveness of pre-employment drug screening as a "quick fix" for drug problems in the workplace (Blum, 1989; Roman, 1989). Basic to these issues is the fact that pre-employment identification strategies directed toward reducing or eliminating any type of employee characteristic or behavior from the work force assume that either direct evidence or reasonable indirect evidence of the existence of that characteristic or behavior will be present at the time of entry into employment. Experience with screening for the recent use of illegal drugs indicates that the bulk of drug-positives are young males from lower socioeconomic settings. Survey data indicate that illegal drug use, as well as serious drug problems, are

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most common among such individuals (Voss, 1980). At present it is not known what proportion of these patterns of drug use represent youthful behavior that will be "outgrown." If data on other deviant behaviors linked to young, lowerstatus men can be generalized, we would expect the substantial majority of these young men to outgrow these behaviors with maturity (Cahalan and Room, 1974). But in contrast to illegal drugs, youthful individuals do not have a monopoly on serious alcohol problems that occur over the life course. Particularly for youth, drinking patterns at one point in time are not highly predictive of later patterns (Roizen, Cahalan, and Shanks, 1978). There is sound evidence that as many as a third of adults who at one time in life have serious drinking problems will "outgrow" or otherwise "spontaneously remit" from these deviant patterns when they are observed several years later (Cahalan and Room, 1974). The converse holds as well: a significant segment of those with apparently normal drinking patterns in early adulthood develop serious problems later on. Further, from what we know about the development of alcohol problems, patterns of serious and disruptive drinking emerge slowly and progressively. The bottom line regarding pre-employment screening for alcohol problems is that serious problems are considerably more likely to surface at some point during an organizational career rather than being evident at its initiation. Thus in sum, both experience and research evidence indicate the importance of an organizational atmosphere in which it is clear that the employer will not tolerate on-the-job drinking. However, although screening techniques may be altered or improved in the future, at present they offer only a very partial solution for dealing with these problems in the workplace. Fitness-for-duty policies that include an explicit focus on employee drinking do, however, provide an excellent context for the implementation of other interventions. STRESS AND ITS PREVENTION Accepting that employers will have to deal with some level of employee alcohol problems in their workforce, a next point for considering alternative strategies is to ask the basic question of whether work and its organization create alcohol problems. If so, what might be done to prevent or alter these forces? There is little doubt of the popularity of "stress" as a universal culprit in our contemporary work cultures and the equal popularity of efforts to control or eliminate it. The definition of stress is frequently intermingled with its consequences, assumed or real. In other words, certain types of experiences, such as perceived work overload, ambiguity of job demands, or nonsupportive supervision, are often defined as stress-producing without full evidence that indeed they do produce these consequences. When such work-based experiences are found to be widely prevalent, the "face validity" of their adverse consequences is often accepted without recognition of other possible dynamics, that is, the rewards that may accompany excessive work effort, the built-in necessity and perhaps stimulation of job-

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related ambiguity, or the interpersonal tradeoffs that may often result in instances of conflict with supervision. At the same time we are bombarded with evidence that many if not most chronic problems with alcohol abuse have a biological base. The biological explanation of addiction is moving as well toward explaining chronic problems that individuals have with other drugs. There is clearly an implicit conflict between this perspective and that which would identify causal factors in the work environment. Such conflict and potential confusion is compounded by the common equation of alcoholism with alcohol problems and with alcohol abuse. No sound research has established that stress alone can lead to alcoholism. However, the available evidence, including that reviewed in chapter 3 by Parker and Farmer and chapter 4 by Martin, indicates that various types of stress can be conducive to alcohol problems or alcohol abuse among employed persons. Although research provides this level of evidence, it is also clear that job-related experiences are neither necessary nor sufficient conditions for the development of alcohol problems. In other words, there are significant numbers of employees with alcohol problems who do not experience significant on-the-job stress, and there are significant numbers of employees who do experience substantial job-related stress and show no evidence of alcohol problems. Can employers' efforts at workplace stress reduction have a significant impact on employee alcohol problems? We cannot provide a sound answer to this question. Although more and better research may come closer to specifying the relationship between these two sets of variables, from the available data it is evident that efforts to change the quality of working life will not eliminate employee alcohol problems and may not significantly reduce their presence. A more reasonable way to frame this question is whether efforts to alter the quality of working life will have a significant and valuable impact on employee alcohol problems. Here also we cannot provide a direct answer. There is no doubt that there is considerable variability across work settings in the sensitivity of management to the stressful conditions of work. We do not, however, have evidence from "crucial experiments" that would indicate that a change in working conditions in a given organization has a direct impact on employee alcohol problems, with a comparison made to a work setting where this change does not occur. The difficulty in assessing the impact of these types of interventions is a problem in research methodology. The impressionistic evidence that is available from comparisons across different work organizations does not afford the experimental control criteria of "all other things being equal." Thus in those employment settings where there is deliberate attention to improvements in the quality of work life, other features are often present as well, such as EAPs, health promotion programs, health benefit coverage that provides for preventive care, and a resultant higher level of employee morale, loyalty, and commitment.

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This makes it difficult if not impossible to ferret out the impact on employee alcohol problems of a change in the quality of work life. There is, however, a compelling practicality in attacking the problem of employee alcohol abuse in a direct fashion rather than waiting until treatment or other interventions are necessitated. As the chapters in this book indicate, attacking the problem through attempting to manipulate or improve the quality of work life is certainly not the only approach to primary prevention. There are other routes such as health promotion programs or controlling the availability of alcohol and job-related drinking occasions. We would not, however, suggest ignoring or abandoning efforts to control working conditions and work stress as a means of dealing with employee alcohol problems. Seeking the direct linkage between particular stressors and employee drinking problems, and then seeking means to eliminate or reduce those stressors, may not be the best means for conceptualizing strategy within the work stress framework. The available evidence, much of which is reviewed in this book, points strongly in the direction of interactions among the demands of work, the psychological characteristics of the worker, conditions of family life, and opportunities for the use of alcohol as a coping mechanism. Few employers would argue that the workplace would benefit from better "fits" between employees and job demands. Thus from this point of view, the consequences of stress in terms of employee maladaptation might best be viewed in the context of general management problems. If a workplace has evidence of a segment of employed problem drinkers who do not care about the interference of their personal behavior with their performance and behavior on the job, then a general management problem that goes beyond employee drinking problems is likely to exist. If we find another segment of employed problem drinkers "locked into" intense and conflicting job and family demands such that the only peaceful and rewarding times of their day are when they are "self-medicating" with alcohol, then we may again be describing a general management problem. In their analysis, which isolates the characteristics of jobs associated with problematic drinking, Parker and Farmer (chapter 3) describe the "unchallenged" and the "burned out" categories of employees that are indicative of problems of management as much as they are problems of employees. All of these illustrations point toward the potential preventive value of increased employer investments in the emerging technologies of human resources management and employee training. In a review of the nature of alcohol problems in American society, Straus (1976), as referenced in chapter 3, points out rather loosely that half the jobs in the United States are too demanding and the other half are not demanding enough. The impact of this "maldistribution" of job and career demands is a compelling base for employers' attention to issues of general human resource management that may have a preventive impact on drinking behavior. For example, job

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demands and employee skills may be matched in a dynamic ongoing and planned fashion rather than assuming that prescribed job ladders and adaptations to new technologies will take their natural courses. At the same time, among researchers who have studied practically any worksite, there is no doubt that selection, training, and support of supervisory personnel commonly falls far short of ideal. Thus there can be little doubt of the potential advantages of considering the prevention of employee alcohol abuse within the context of more generic forms of organizational development that reflect strategic planning for human resources management. A quite different but parallel potential in approaching the primary prevention of alcohol problems through organizational development is pointed out in chapter 12 by Reichman and Gugliemo. There may be potentials for primary prevention that are built into strategies of identification and treatment, which simply go unrecognized. As these authors describe, an EAP that includes careful collection of information about the sources of its caseload can function to monitor the workplace to detect areas of stress and disorganization. In other works, a datasensitive EAP has knowledge of where in the workplace referrals are coming from and the nature of work problems that are described by EAP clients from different sectors of the workplace. The EAP can thus provide vital input into the design and content of organizational development strategies that may have preventive and cost-containing impacts. Such a use of the EAP is commonly overlooked for several reasons. First, its functioning may simply lie outside strategic human resource planning. This is typically a pattern of "benign neglect" that may be encouraged by EAP administrators who emphasize confidentiality as the defining characteristic of their programs and who thus resist interaction and integration with other human resource management functions. Second, the EAP may be incorporated into organizational culture strictly on the basis of its treatment and counseling emphasis, with these "cultural blinders" precluding recognition of its broader preventive potential. Third, the EAP may not have an effective system of data management, which includes capabilities for data analysis, so that its potential role in organizational development is simply lost. Concluding this discussion of managing stress as a preventive strategy, we see problems with the manner in which the issue is framed. It is unlikely that there is any set of identifiable and measurable job experiences that distinctively lead to alcohol abuse or alcoholism. This should not detract from research findings that such forces may be contributory. Addressing stress and reducing its impact appears to be a localized matter more than an opportunity for a set of researchbased generalizations about features of the workplace that should be altered. Placing the stress issue in the context of general management and strategic planning appears a better approach than regarding it as an isolated strategy that would operate in a manner paralleling immunization or other public health approaches.

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DIFFERENTIAL DISTRIBUTION OF ALCOHOL PROBLEMS ACROSS OCCUPATIONAL AND ORGANIZATIONAL CULTURES Building upon the previous section as well as upon material presented in this book about occupational cultures and individual careers, it is clear that both organizations and individuals vary in the extent to which drinking and drinking problems are risks associated with given jobs and given "seasons" in individuals' life careers in organizations. As I indicated some years ago (Roman, 1982), the basis for designing workplace interventions may depend on the relative dominance of occupational or organizational structure and culture in the flow of work activities. At one end of this continuum, a single occupation or a group of occupations is dominant. Here it is important to consider the following three elements when strategic decisions are made regarding alcohol problem interventions: (1) the manner in which work is organized in the dominant occupation, (2) the relationships between peers practicing the occupation, and (3) the characteristics of the culture of this occupation. There is a very marked and important distinction between the notion of collective occupational norms as facilitators or inhibitors of drinking and the notion of individually experienced work "stress" as a primary cause of employee drinking. The differential opportunities that occupational activities allow for drinking may be an important variable in the development of drinking problems. This is clearly indicated in the detailed analyses provided in chapter 6 by Fillmore and in chapter 7 by Ames and Janes. An important distinction can also be drawn between occupational subcultures and occupational drinking cultures. It is very clear that some, but not all, occupational groups have norms that significantly direct their members' drinking and other substance use. In some instances, observations such as those of Ames and Janes (chapter 7) indicate that on-the-job drinking becomes normative, accepted, and even integrated into work group management. In other instances, we find genuine drinking-problem subcultures, as has been shown in studies of the Tunnel Workers Union in New York City (described in part in chapter 16 by Sonnenstuhl and chapter 22 by Trice) and of unionized seamen in the Port of New York (Molloy, 1989). In an oral presentation at the conference on which much of this book is based, M. W. Perrine articulated the very important notion of the "highway as a workplace" for long-haul truck drivers as well as many others for whom driving is a central occupational activity. Within "highway culture," there is known to be significant drinking and drug abuse, but there is relatively little knowledge about the norms related to drinking and drug use. Thus occupations vary in both their opportunity structures for drinking and the occupational norms that may accumulate in association with drinking. However, much more attention is needed in defining and viewing drinking behavior within occupational frames of reference.

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Moving from the dominance of occupational cultures to the other end of the continuum, we find organizational dominance. This is typically a setting where there is a considerable mixture of occupations (Roman, 1982). Here the task of designing interventions is at once both simpler and more complex. The major focus should be on the structure of organizational relationships between positions, which is the basis for assessing differential opportunities or risks for problematic drinking (Roman and Trice, 1970). Obviously there can be great variation across a multitude of such relationships within a large organization. Organizational dominance is found in those settings where there is a great deal of attention to organizational culture and identity. Companies that have gained attention as the "best places to work" probably come closest to fitting this characterization, although those known as the "worst places to work" probably fit it as well. The distinction centers on the extent to which an organizational culture can be identified, and this may be negative as well as positive. The dominance of organizational form is more likely in larger organizations, although not exclusively so. A good index into the relative dominance of occupation or organization is the manner by which individuals identify their employment: do they "think first" of the occupation or the organization? Further, do career aspirations center on movement within the organization or on a better occupational position in another organization? Between the work settings dominated by occupational or organizational forms are those characterized by both. It is in these "in-between" forms that we would likely classify many if not most workplaces. In such settings we would find multiple occupational subcultures, but there are many possible variations, including settings where small numbers of different occupations are organized around one or two dominant occupations, such as the centrality of the professoriate in the college or university, or the dominance of physician groups and nursing groups in hospitals. A further and very important variant is the presence of labor unions or other employee organizations. Unions vary greatly in their social structure and influence upon members, and their presence often (but not necessarily always) indicates occupational dominance in a given workplace. Indeed many contemporary unions are organized around industries rather than occupations. It should not be overlooked that the concept of a union includes associations and societies of professionals that may be very influential in guiding and controlling members' drinking behavior. When professional employees are present in a workplace, the influence of these affiliations on them should be kept in mind. In some instances, either craft or industrial union locals may be very potent in promoting interpersonal solidarity and the consolidation of unique cultures that may include drinking norms. Lest unions be inappropriately stereotyped as passive promoters of alcohol problems, it must be emphasized that unions have shown strong interest and involvement in the development of alcohol problem rehabilitation programs (Sonnenstuhl and Trice, 1987; Roman, 1988; Molloy, 1989). There are minimal data on the actual prevalence of union-based efforts

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to systematically deal with members' alcohol problems, or on the effectiveness of these efforts. Nevertheless, the "insider" interest and commitment to action toward alcohol problems among union members constitute a key to effective dealing with alcohol problems in many organized occupational groups. When considering the design or mix of intervention and alcohol control efforts in the workplace, it is critical to examine the placement of a given workplace on this occupational-organizational continuum, adding to this consideration of the effects of union presence. This derivation of the need for such "customized" program design is a crucial example of where the possibility of a single "recipe" for workplace efforts to address employee alcohol problems is fallacious. One key difference may be that in settings where occupational structures dominate, there are norms in place that must be considered if new norms are to be imposed or superimposed on existing structures. Although the introduction of any kind of organizational programming typically calls for a "needs assessment," this consideration recalls my earlier comments about such surveys. Rather than simply looking at numerical estimates of problem-drinking distributions, good planning may require expert external consultation in obtaining an overview of the differential distribution of alcohol problems across and within occupational and organizational mixes and subgroups. Crucial to such an overview is an understanding of the normative structures that are already in place to facilitate such problematic behavior. Conversely, attention should also be paid to normative structures in work groups that already provide constructive strategies to address such issues. Clearly there are some occupations that have subcultures in which drinking is very common among occupational members in off-job settings. What is commonly overlooked by clinically oriented researchers are the strong normative controls in these group settings that may act to prevent the interference of drinking with job responsibilities and/or act to curb the behavior of those whose drinking becomes excessive and problematic. Constructive "stress management" and positive interactions among work peers (and between workers and supervisors) may characterize these patterned uses of alcohol to "blow off steam" and resolve work-related tensions and difficulties, resulting ultimately in benefits to work quality. All too often the introduction of "planned social change" ignores such instances of "indigenous social control" and is instead guided too much by commitments to innovations. Effective structures that are already in place should be nurtured and integrated into new strategies rather than undermined or destroyed. Two recent studies of union-based occupational problem-drinking subcultures both describe the transformation of a portion of the problem-drinking subculture into a recovering alcoholic subculture; it was found that the norms that so strongly supported and facilitated problem drinking could be harnessed to provide equally strong occupationally based support and facilitation for recovery from alcoholism (Sonnenstuhl and Trice, 1987; Molloy, 1989).

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DIFFERENTIAL DISTRIBUTION OF ALCOHOL PROBLEMS ACROSS INDIVIDUAL CAREERS At a distinctively different level of analysis is the issue of alcohol problems and careers. As is clear in the discussion in chapter 5 by Richman, alcohol use may show differential patterns in association with phases of career development. As individuals move simultaneously through their work careers and their life courses, needs and values change. Practically all persons must face the "topping out" of their careers. When this occurs, the work-related factors that earlier acted as motivators diminish in importance, and tolerable frustrations become intolerable. As future mobility becomes more unlikely, the previously committed and involved employee may become hostile and resentful to authority, especially to the extent that such authority symbolizes the continuing upward mobility of others. At the same time, one cannot ignore the sheer boredom that can occupy blocked career mobility and the perceived absence of challenge within the work role. There may be considerable benefit when employers provide for continuing career development and offer opportunities for lateral changes and new challenges for the employee whose further upward mobility has been blocked. Although it has not been systematically investigated, one of these major benefits may be in the prevention or curbing of developing alcohol problems among those whose upward mobility opportunities have ended. An illustrative example is found in the current work of David Machell who has coined the term "professorial melancholia" to describe career-related problems among academics (Mooney, 1989). Describing patterns that generalize to other professions, Machell indicates that extreme perfectionism and the lack of clear external standards for judging performance characterize academic careers. These joint features of occupational and organizational life lead many professors to a state of low self-esteem and disillusionment, which may peak at midcareer. Machell ties these affective states to significant risks for alcohol and drug abuse. At the same time he points out how low self-esteem undermines the motivation for quality job performance among academics. Machell's suggested approach to professorial melancholia is to reduce the centrality of the job as the source of self-esteem. Such centrality of work in one's life (loosely referred to by some as "workaholism") is a problem that characterizes many professional and upper management employees other than academics. Reducing this centrality requires counseling and deliberate attempts at career development. These services are frequently missing in workplaces, with a tendency for many managers to view them as superfluous or as necessary only at times of organizational drama such as downsizing and outplacement. If present, career development services tend to be concentrated on youthful employees who exhibit promise for upward mobility and increased leadership within the workplace. Deliberate introduction of such preventive interventions in workplaces is not simple and must be set in a broader context. Such career development

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initiatives, directed at all age levels within the workplace, are certainly not an appropriate mechanism for workplaces in which other elements to support such development are not present. Such an innovation will only have utility if it is part of a broader strategic plan for human resources management that includes commitments for a serious programmatic implementation. Two other factors relevant in considering the development of drinking problems over the course of individual careers are competition and external demands. Demographic descriptions of the U.S. labor force indicate that the Baby Boom generation will continue to pass through midadulthood during the next decade. Accepting the fact of the pyramidal structure of most organizations and the relative size of the Baby Boom cohort, it is evident that there is and will be relatively intense competition for mobility into positions at the top of organizations, as well as for positions "toward the top." These processes guarantee considerable disappointment among those who will inevitably fail in their mobility aspirations. Such competition brings with it a variety of stresses. Of particular significance are the adaptations to competitive stress as well as the adaptations to both success and failure that are conducive to alcohol abuse and problem drinking (Roman, 1970; Roman and Trice, 1970; Trice and Belasco, 1970; Roman, 1974; Roman and Blum, 1984). These studies have revealed what might be unexpected associations between "success" and drinking problems, highlighting such phenomena as: Competitive exploitation of those in high positions in which peers may either work to cover up evidence of alcohol problems and at the same time encourage their further development. The peculiar pressures that "greedy audiences" place upon those who are defined as "stars" in various social circumstances, and the pressure produced by the steady scrutiny of the activities of such individuals. Risks associated with mobility into settings that lack social controls around drinking behavior that characterized prior positions. The remarkable opportunities for "hiding" that are associated with high social status.

Sensitivity to structural transitions associated with "success" is important for human resources management and may offer opportunities for preventing or curbing developing alcohol problems through counseling and follow-up of those experiencing major transitions. Pressures created by work-family conflicts are clearly on the increase. At present and in coming generations, employees will be facing new and different forms of external demands that may create intense stress and ambivalences toward work, which may be conducive to drinking as a coping mechanism. The nature and intensity of these demands change dramatically across individual careers and life cycles. As is well described in chapter 13 by Googins, the labor force is rapidly moving to a situation where the majority of employees are in a dual

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employment marriage. Issues of child care and eldercare are at present largely unresolved, and they loom in importance as future demands on typical families where both adults are employed. More subtle than these relatively clear-cut demands are the necessities for mutual adaptation of spouses to their partners' career contingencies. This may lead increasingly to flows in the labor market where professionals and other skilled persons are employed in positions that do not represent their first or even their second choices. Such flows reflect the adaptation to a spouse's career requirements in terms of a geographic move, placing individuals in jobs poorly matched to their skills or aspirations. Thus the sensitivity of employers to the increasing intermingling of the social institutions of work and family through proactive programming and benefit provision may constitute avenues for preventing personal drinking patterns that are readily available means to cope with frustration and disappointment. ISSUES IN THE DESIGN OF EMPLOYEE ASSISTANCE PROGRAMS Many of the chapters in this book are concerned with the EAP strategy as a means for dealing with employee alcohol problems. Some of the authors touch on numerous issues that should be of concern to those considering EAP implementation or those interested in maximizing the utility of an existing EAP. For the remainder of this chapter, I review five areas of concern about EAPs: features of EAP design; factors related to the alcohol-problem emphasis observed within EAPs; the integration of EAPs with parallel activities in human resources management; the assessment of an EAP as a programmatic activity; and the emerging importance of client follow-up as a critical activity to assure payoff from investments in EAPs. A major issue in the design of any programmatic service in the workplace is its location. In the case of EAPs, the choice of location is either within the workplace or through contract to an external agency (Blum and Roman, 1987). Location is not, of course, the single factor determining an EAP's success. The success of any programmatic innovation is tied to the resource allocation that accompanies it; likewise appropriate staffing is a key issue. As is evident below, both of these issues are intertwined with EAP location, an important consideration for the guidance of planning. The basic model for the design and marketing of EAPs in the early 1970s was the internal program. This typically consisted of an on-site organizational employee working under the guidance of an organizational policy and under the direction of either the medical or human resources management function in the workplace (medical department location tended to be more common in these earlier days than is the case at present) (Roman, 1988). Generally these program administrators performed the entire range of tasks associated with the EAP and typically enjoyed a high degree of autonomy.

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The design where a workplace wrote a contract for EAP services with an external provider organization first emerged in the mid-1970s. This development stemmed from two forces. First, as a means to greatly expand the numbers of persons identified and treated for alcohol problems, field consultants were supported by federal grant funds to the states to develop prototypical EAPs in any and all workplaces in their respective states. These consultants were initially concerned that the basic internal model of an EAP did not fit the resource availability in the typical medium-size or small worksite. Several of them found that smaller organizations were receptive to the provision of EAP services from a central external location. As this model developed, it became attractive to larger organizations as well, for reasons described below. Different types of service providers emerged, with their organizational bases including local councils on alcoholism, alcoholism treatment agencies, "consortia" specifically established for this purpose, and free-standing, for-profit service provider organizations. This leads into the second force contributing to the growth of the external model. As the EAP concept broadened to include coverage of problems in addition to alcohol abuse, entrepreneurial service providers were attracted to this new and dynamic area of human service delivery. Until this time, the provision of services related to substance abuse or psychiatric problems had been directed toward lower status and underemployed clients through publicly funded organizations, whereas the middle and upper classes found needed services through routes that were very individualized and atomized. To a considerable degree, EAPs represented an array of opportunities through the "opening" of the workplace as a vast new source of clients. These programs created considerable interest and excitement among human service providers, interest that continues to grow at the present time. The external contract model has flourished. Where the external model first emerged as a response to the perceived needs of small organizations, it can now be found in organizations of virtually any size. The external program model has proven especially valuable to large multilocation companies where employees are widely dispersed in settings which vary greatly in size. Utilizing external EAP contracts is the only practical means of policy implementation when the organization is committed to providing nationwide services that have common features and are of approximately the same quality. Data from our own research, which is described in part in chapter 10 by my collaborators Blum and Bennett, indicate that newer EAPs are more likely to be based on external contracts. A major factor contributing to this trend is the limitations on the creation of new positions that became common across a great many organizations in the late 1980s. Because a new position is usually a necessity for an internal EAP, many settings have had no alternative but to use external vendors. However, it is not at all unusual for these contracted programs to have all the trappings of an internal program. It may be possible to contract for 100 percent of the services of a contractor's employee and have this individual

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essentially perform all of the functions of an internal EAP administrator without creating a new position. There is no basis for the recommendation of a single program model for all workplaces or even for most workplaces. There is, however, an issue of overriding importance for the effective organizational management of either internal or external EAPs. In our 1984-1985 study of 439 company sites with EAPs (discussed in more detail in chapter 10), it was clear that external EAPs were utilized at very low rates by either managers or employees when these EAPs lacked a meaningful "liaison" manager in the workplace. Why was this liaison important? While an EAP service was in place and theoretically accessible, there was no mechanism within the workplace to legitimize the EAP or promote its use. My own research over the past 20 years has repeatedly shown the importance of evidence of managerial support of an EAP for that EAP's effectiveness, that is, persons lower in the organizational hierarchy use the service because they perceive that it is accepted and supported by those above them. The visible liaison, represented by an organizational manager typically in the human resources function, can comprise this ongoing, day-to-day evidence of managerial support. In organizations with reasonable levels of usage of an externally contracted EAP, our research showed that this liaison manager had a formal assignment as the contract supervisor, often with a specific proportion of time designated for these responsibilities. Less formally, this individual functioned as a ''gatekeeper" and "clearinghouse" for those in the workplace who needed advice or information about possible usage of the EAP services for a particular problem affecting themselves or subordinates. Especially in large organizations, it was clear that without an internal liaison, supervisors and managers were unlikely to directly contact the external agency for assistance in dealing with a subordinate. Whereas it is true that EAP usage requires knowledge of the service and what it offers to supervisors, union stewards, or employees, the diffusion of information is simply not enough, that is, it is a necessary but not a sufficient condition for EAP usage. Our finding of the low usage of "unlinked" EAPs was not simply a function of knowledge of the service but also of "social distance," the extent to which supervisors and employees felt that there was someone within the workplace who knew the contractor and the manner of service delivery. Such liaison persons could temper concerns that the referral of the employee would be pressured prematurely or that a supervisor attempting to use the EAP would encounter an external functionary with whom communication could be difficult. It would be naive to conclude that there is no parallel need for a liaison role in a workplace with an internal EAP. Here, however, the prescription is less straightforward. The importance of deliberately establishing managerial roles that link the internal EAP into organizational functioning depends on the extent to which other features do or do not contribute to the EAP's integration into the formal side of organizational life. In considering the liaison role for internal programs, it should be recognized

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that in most organizations the activities performed by the EAP are unique, that is, dealing with serious (and often confidential) personal problems affecting employees' lives and work. To that extent, the internal EAP administrator is an "organizational loner" in that no one else does what he or she does and no one else particularly understands this work. Given the nature of our cultural attitudes toward personal problems, there is even a subtle pressure on some to deliberately avoid an understanding of these processes ("I don't want to know what goes on in there"). Finally, our research has shown that many individual EAP personnel cultivate an image of their occupational uniqueness in organizational life; they actively and consciously believe that their success will be undermined if they "fit in" too well. This "loner" status may be exacerbated by concerns about client confidentiality that are so intense that they constitute the primary basis for the EAP's identity. In some organizations this attitude may be associated with the physical placement of the EAP office at some distant and "hidden" location, further distancing the EAP adminstrator from organizational integration. In our research it is clear that an internal EAP should be managed with close attention to its integration into other aspects of organizational functioning. Whereas most activities within organizations become integrated in a rather automatic fashion, there are built-in pressures against EAP integration, primary being the emphasis on confidentiality. In contrast, deliberate efforts can make the EAP a distinctive and integrated partner on the human resources management team. Any internal EAP will benefit from "champions" who are placed throughout the management structure as well as in the union ranks. These persons may promote the importance, utility, and credibility of EAP activities, fulfilling the gatekeeper and clearinghouse functions associated with the liaison to the externally contracted EAP. Under circumstances where structural developments have minimized integration, the designation of such internal liaison managers may be crucial for the EAP's effective success. An assessment of the EAP's integration is the basis for deciding how deliberate the liaison process needs to be in terms of its development and ongoing visibility. Beyond the critical item of organizational liaisons, other considerations that contrast the varying advantages of internal and externally contracted program models are control, access, flexibility, accountability, and organizational culture. Control This issue stems directly from consideration of the liaison role. At first it would appear that organizational control is greater with internal EAPs. Those who operate the program are organizational employees subject to internal supervision and performance evaluation. Depending on the nature of a particular workplace, the internal EAP can be held accountable for its use of resources. Reports can be obtained on an ad hoc basis with minimal delay.

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However, control of an internal EAP carries the responsibility for adequate and informed supervision and direction. Human resource managers responsible for supervision of an EAP unit must have the skills to assess the individual and collective performance of EAP staff members. In general, contracting for services with external providers frees the workplace from the responsibilities of providing direct supervision. The external contract should offer assurance that the supervision provided within the contractor organization is competent to assess the performance of those employees who are assigned to the contract. Under these conditions, however, it is obvious that both the visibility and control of the performance of EAP personnel drops considerably. The apparent advantage of control associated with an internal program carries with it the cost of commitment by the workplace, commitment that extends to the continuing development of the EAP administrator as a career employee. This commitment may be considerably less significant in the context of the workplace making an annual decision about renewal of a contract, the substance of which is carried out by an external provider. Theoretically, there is much lower organizational commitment with an externally contracted program. If management is dissatisfied with the effort or believes that the funds would be better allocated elsewhere, termination can conveniently occur at the time of contract renewal. Dismantling an internal program with staff who are company employees may be considerably more problematic through its disruptive visibility. Such a move could activate constituencies that the EAP has built within the workplace. In contrast, this may be a function of the image that the EAP has developed within the work force. Some internal programs are more likely to be visibly integrated into the workplace's disciplinary system and are thus less likely to be perceived by employees as a benefit that may be lost. Under these conditions the EAP may be less likely to be protected by collective employee sentiments. If an externally contracted program is widely perceived as a benefit among the work force, forces for its maintenance may equal those sustaining the permanence of internal programs. Access The adoption of an EAP indicates that it should be used, and its use depends on its accessibility. From a physical perspective, the in-house EAP may be more accessible. However, if suspicion is high and desire for secrecy great, that physical accessibility may be a barrier to program use. For example, the opportunity to go to an external EAP provider's office on the other side of town may be attractive to many employees in contrast to an office on company property. Thus an off-site location may facilitate use of the EAP on a self-referral basis. When considering the use of an EAP in dealing with job performance problems, it is important to look beyond employee access and consider the accessibility to supervisor, managers, and union stewards. The research study of 439 EAPs

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noted earlier (Blum and Roman, 1989) indicated that providing consultation to supervisors and managers is one of the most central activities of the internal EAP administrator. This occurs when a supervisor believes that a problem that has developed around a subordinate's job-related behaviors is the type of situation described in the EAP policy. Rather than attempting to "go it alone" on the basis of recollections about the policy, the supervisor contacts the EAP for advice on what steps to take. This consultation is usually critical in bringing about effective confrontation and referral of employees with alcohol problems. The earlier such a confrontation occurs, the greater the likelihood of the employee's successful recovery and the less the losses to the workplace (Blum and Roman, 1989). Here the advantages of the internal EAP are clearcut. Busy managers are more likely to take the time to contact an individual within the workplace who is known to them than to identify and contact an off-site facility where they will have to explain themselves to an unfamiliar functionary. Accessibility for supervisory consultation is enhanced by the visible presence of the EAP staff on a routine basis, increasing the likelihood of their being utilized at a time of crisis. The internal program advantage can, however, be at least partially overcome by the external provider who routinely stations program staff in the workplace. Flexibility Changing demography of an organization's work force may require flexibility in the design and operation of an EAP. From one perspective it is likely that the internal program will be more adaptable to change if the fixed-fee contract with the external provider does not allow for a quick response in altering services to the work force. This need not be the case, although most external providers match their staffing on a particular workplace contract very closely to their contractual commitments. In contrast, the response to change by an internal EAP may be greatly limited by the skills that are represented within the staff. Thus permanent, in-place staff may limit an EAP's flexibility. Should unexpected needs arise, a sophisticated external provider may more readily act as a broker in identifying and securing the skills in the community that are necessary for responding to demands that occur in a particular workplace.

Accountability Our study of 439 EAPs (Blum and Roman, 1989) revealed that relatively few managements scrutinized EAP operations by requiring routine data-based reports or by allocating organizational funds to support formal external program evaluation. EAPs in many cases are maintained on the basis of "face validity." Managers observe that employees are helped by the program and/or managers know of other managers who have been freed by the EAP from a trap of trying

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ineffectively to cope with a troubled subordinate. When such "lore" pervades workplace life, there is little argument that the EAP is doing its job. In terms of the potential for collecting information on EAP effectiveness, our observations indicate considerable advantage in internal programs. Not only are data more readily accessible in internal EAPs, but the possibilities are greater for ready linkage between program participation data and other job-linked behaviors such as attendance records, health care usage, disabled worker compensation, and job performance. The external contractor often minimizes reports back to management within the context of sustaining confidentiality. Usually the simplicity of these reports reflects the minimal access that the contractor has to work-related information about clients. Further, many external providers maintain records about program usage and outcome in a standardized form across the different organizations that have service contracts instead of customizing data collection for each contracting workplace. This may make difficult the assessment of an externally based EAP according to criteria that are unique to a particular worksite. It is critical to add that our research has shown (Blum and Roman, 1989) that the majority of both internal and external EAP administrators perceive considerable shortcomings in the evaluation and data management associated with their programs and are actively seeking both guidance and means for improvement. Organizational Culture An intangible consideration centers on the match between the program design and the workplace culture. Such an assessment centers on the extent to which employees will be ready, willing, and trusting in their use of an internal service as contrasted to utilizing such services totally outside organizational walls. This consideration centers not only on employee willingness to use a service, but also on supervisory readiness to rely on internal versus external (e.g., "neutral") consultation and assistance in dealing with a troubled employee. The acceptability of a service may relate to employee orientations toward different staff departments. An organizations's human resources staff might not be readily used by the work force or supervisors for EAP services, but this need not hold true for the medical department. Several creative designs have placed the EAP directly within the workplace's line functioning because of the perception that optimal use would occur under such arrangements. The workplace culture is also an important consideration in the selection of internal staff. In our study of 439 EAPs (Blum and Roman, 1989), we found some programs that were externally contracted because the organization was unable to identify an individual to function as an administrator of an internal program. The qualifications important for effective EAP work include substantial knowledge of organizations, human resource management, industrial relations, employee benefits, and other dynamics of the workplace. It is important to underline that strong clinical expertise is not vital for this role because external

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professionals can be used to carry out clinical assessments. Empathy and credibility in working with others are, however, critical features. The context of these qualities should be centered on good basic knowledge of how workplaces function, the "bottom lines" of EAP staff qualifications. Such qualities can often be obtained by assigning a current employee to function as EAP coordinator. If this is not possible (and our data do indicate that most internal coordinators are hired from outside), then it is important to systematically evaluate candidates along the same lines and with similar criteria that we have suggested for looking at external contract providers. In sum, the design of an EAP needs to take many features of the workplace into account. Frequently this can be accomplished by employing a consultant with EAP expertise who is free from any associations with EAP service delivery and who has sound credentials in the evaluation of data. To be effective, this consultant must also have the skills to work with a broad cross-section of organizational representatives in developing an overview of a workplace's EAP needs. BALANCING ATTENTION TO ALCOHOL PROBLEMS AND OTHER EMPLOYMENT-RELATED ISSUES A major problem in the management of EAPs is the content of the caseload. Frequently, the clinically dominated frames of reference of EAP specialists would indicate that an EAP's effectiveness should be judged by the overall extent of program use, that is, the number of cases seen relative to the size of the work force. This is indeed a good measure of effectiveness when the employer is attempting to project the image of the EAP as a significant new employee benefit. However, it is our firm belief that the use of EAPs as benefits is inappropriate and that most employers maximize their EAPs' utility by keeping them focused on employee problems that are related to job performance. At the very least, clinical frames of reference that focus attention exclusively on the troubled employee as a "case" underestimate the potential impact of EAPs. Although it might be debated that any and every personal problem of an employee and members of his or her household can impact job performance, it is evident that the EAP's attempt to grasp broadly around all such problems can be costly in terms of services. Extension of EAP services beyond work performance issues may not only be inordinately costly, but the paternalism and implied commitment of the employer to overall employee/dependent life improvement may have undesirable long-run consequences. In our field research, which covers many different types of data collection, it is very rare to find EAPs that have difficulty in generating referrals. Indeed, most EAP personnel appear markedly overworked by the demands made on their time in dealing with their caseloads. In the majority of instances, these heavy caseloads reflect high rates of self-referrals. High rates of self-referrals offer several dilemmas to organizations that have

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established an EAP as a mechanism for dealing with alcohol problems in the workplace. First, as is made clear across most of the chapters in Part II of this book, there are many barriers to motivating supervisors to utilize resources dealing with problems that they may define as "their own" and within their span of authority. Whereas some of these natural barriers are detailed below, more basic is the definition of "counseling" as a central part of the supervisory role. A widely used supervisory text (Chapman, 1990) offers an excellent illustration of this dilemma. It gives detailed information on how a good supervisor is able to "handle" performance problems without involving others in the workplace, the key technique being "counseling." EAP training contrasts sharply with this emphasis by urging that supervisors refer troubled employees to the EAP, avoid trying to diagnose the nature of the problem themselves, and avoid the entrapments that can develop if supervisory "counseling" is attempted. Here the EAP philosophy is directed toward disengaging supervisors from the troubled employee, whereas other descriptions of "good supervisors" push them toward such engagement. The picture is confounded further when, as an apparent afterthought, Chapman (1990) adds a brief section suggesting that supervisory counseling with the chemically dependent employee may not be such a good idea; yet he still suggests that supervisors themselves endeavor to get chemically dependent subordinates to treatment, without any mention of the use of an EAP. A second dilemma lies in the definition of the EAP within the workforce. As much of the material in this book indicates, supervisory referral has many advantages. Two central advantages are documented evidence of employees' performance problems and the leverage of this evidence in motivating the employee to take seriously any opportunities for treatment and behavior change. Yet by its invitation to employees to seek assistance with problems that they perceive are affecting their work, it is very difficult for the EAP to "shut off self-referrals and devote most of its energies to stimulating supervisory referrals. Third, there is clear evidence that self-referrals are less likely to be associated with employee alcohol problems (Blum and Roman, 1989). The nature of alcohol problems contravenes a model of personal help-seeking except at the late "crisis" stages. Thus one would expect few employees with alcohol problems to go to the EAP on a "true" self-referral basis. However, it is increasingly clear that many apparent self-referrals constitute suspected alcohol abuse problems that have sought the EAP as a result of supervisory "nudge" or suggestion. Although the supervisor may believe that this is a responsible and adequate action, the EAP provides the referred individual with total confidentiality except in the case of a formal documented referral. Thus in a case of "nudging," the employee is in control of revealing information about drinking behavior as well as job performance behavior. The employee can thus "work" the EAP by satisfying the supervisor that help is being sought, at the same time convincing the EAP staff that the underlying problem concerns something other than drinking. Ultimately the "real" problem may be revealed,

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but in the interim poor performance and other losses can persist, and the "nudging" supervisor may come to perceive the EAP service as ineffective. Despite the fact that a strong self-referral emphasis can act against the realization of maximum payoffs from an EAP and that such an emphasis may undermine an optimal emphasis on employee alcohol problems, as a "preferred option" self-referral has many social and organizational supports. What are the factors that support a self-referral emphasis within EAPs? First, both in terms of common sense and as part of the "lore" of the EAP practitioner community, self-referrals are regarded as indices of the EAP's acceptance and its credible reputation within the workforce, that is, employees became aware that the program provided helpful and confidential services and thus were ready to take advantage of the services without pressure or confrontation. An obvious question is whether self-referrals are drawn from the same subpopulation of the workforce as supervisory referrals; impressionistic evidence indicates that many self-referrals have not yet experienced a decline in job performance, but this has not received adequate study. If the assumptions about the dynamics of self-referral generation are correct, it can be assumed that selfreferrals generate more self-referrals, with credibility and support for the program growing in a corresponding manner. Second, it is clear that self-referrals provide for program visibility and activity. It is obvious that newly introduced EAPs will not be immediately used by the work force and require stimulation other than supervisory training or management directives to use the program. Publicity about the program's availability to provide help for all sorts of employee problems coupled with knowledge of the ready availability of the program coordinator, perhaps through a telephone "hotline," can induce both program visibility and use, with the employees selfselecting the problems for which they desire EAP attention. The problem here is that self-referrals can rapidly increase in number and demand the lion's share of EAP resources in attending to them. This clearly reduces the available resources for the staff to provide training to supervisors about their EAP-related roles or to be visibly available to consult with supervisors who are attempting to deal with difficult employees with alcohol problems. Another set of supports for self-referral centers around the strategy of constructive confrontation, described in detail in chapter 10 by Blum and Bennett, chapter 16 by Sonnenstuhl, and chapter 22 by Trice. Self-referral may be viewed as an alternative to using a confrontation strategy. However, as indicated above, what appears to be a self referral may actually be an "informal" supervisory referral. This alternative may be selected by supervisors because they desire to avoid the red tape and potential "messiness" of a direct confrontation. By "nudging," supervisors avoid the entanglements of a formal confrontation and employees are able to preserve the dignity of appearing to seek assistance apparently "on their own." As noted, this limits the EAP's access to important information about the client, which may prevent efficient case management. Indeed there is evidence

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to indicate that formal supervisory referrals of employees with alcohol problems result in marked reductions in sickness/absenteeism following the referral in contrast to employees with alcohol problems who enter the EAP via an informal supervisory referral (Amaral and Cross, 1988). Self-referral may also be encouraged by the program coordinator who views the constructive confrontation strategy with skepticism and as contrary to the spirit of human service-based intervention. Whereas "reality therapy" and some other confrontive approaches have had attention in clinical practice, the vast majority of counselors and parapsychiatric practitioners tend toward approaches that emphasize insight, self-awareness, and self-diagnosis. Thus self-referral may be directly or indirectly encouraged by program practitioners who are simply uncomfortable with the tone and flavor of constructive confrontation. Two further "twists" complicate the untangling of the supports for the selfreferral emphasis in EAPs. As has already been implied, EAP work now includes practitioners who are not grounded in alcoholism intervention or treatment (Roman, 1988) and to whom the traditional "tough love" strategies of AA are foreign and strange. This does not represent an invasion or cooptation of an occupation that should be reserved for alcoholism specialist, for with the move to the broader EAP model, it is evident that a knowledge base in psychiatric intervention is certainly relevant. Boundaries around the EAP arena have until recently been poorly developed. The transformation of workplace programming into the EAP mode has greatly broadened the base for recruitment of EAP workers. The diffusion of EAP has been driven in large part by commercial forces as the external contract approach has become the dominant form of new programs. Changes have thus occurred without critical sensitivity to the skill base essential for effective EAP work, the definition of which is clearly not a matter of consensus, although the credentialing process currently underway forges a higher level of agreement than has been obtained in the past. In any event, it is clear that many have legitimately entered EAP practice without an alcoholism grounding and whose professional preferences do not include the rough-edged tones of confrontation more common among earlier practitioners. Related and equally problematic is the manner in which constructive confrontation, conceptualized and designed for use with employee alcohol problems, should be utilized in a broad-based program dealing with psychiatric disorders and other personal problems. It is clearly inappropriate to recommend the use of a blunt confrontive strategy across all circumstances of deteriorated employee performance, and the choice of its use can be guided by effective use of the supervisory consultation strategy of the core technology. If this consultation is not in place, however, such as in externally based programs not readily accessible to supervisors, the program coordinator may not consider the possibility of constructive confrontation because of the depth of supervisory involvement required. Indeed, program coordinators in such settings may already be ideologically opposed to constructive confrontation, reflected in the manner in which the program was designed in the first place.

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The self-referral emphasis may be viewed as an unanticipated side effect of the implementation of the EAP model as an improved version of the industrial alcoholism program model. In any event, self-referral has become the dominant means of referral in most EAPs, which many doubt as being effective in "really" reaching the optimal number of employees with alcohol problems from which the EAP gains a great part of its cost effectiveness. THE INTEGRATION OF DIFFERENT STRATEGIES OF INTERVENTION AND CONTROL Although EAPs represent the principal mechanism that workplaces have adopted to deal with employee alcohol problems, a repeated theme of this book is that they are not the only means for accomplishing these goals. At the same time it is also evident that the vast bulk of the research that has been reported is concentrated on EAPs. Earlier in this chapter I considered aspects of the integration of fitness-forduty policies with EAPs, and I repeat that the two policies can be mutually supportive. Similar logic of mutual policy support applies to any effort directed toward reducing drinking among employees at all levels of organizations. The key, however, lies in the consistency of policies with one another and the extent to which they are deliberately integrated into overall strategic human resource management planning. Although there is a strong argument for internal consistency across policies on the basis of the opportunities for litigation that inconsistencies afford, an equally practical consideration lies in the concept of mutual support among different policies that are centered around similar issues. When policies contradict one another or are administered in isolation from one another, employee and management noncompliance is encouraged. This noncompliance is supported by inconsistencies that in themselves indicate to the work force that management is not really serious about addressing a particular problem. Examples of such inconsistencies include a fitness-for-duty policy that leads to immediate discipline for on-the-job alcohol use or intoxication, accompanied by an EAP policy that allows for confidential employee self-referral when an alcohol or drug problem is suspected. Such inconsistency encourages supervisors to informally "nudge" employees with fitness-for-duty problems to appear at the door of the EAP as a self-referral. Likewise such inconsistency can spread the word within the workplace culture that the EAP is the place to go as a selfreferral if an employee wants to be "bullet-proofed" against adverse disciplinary actions. A further example would be a tough fitness-for-duty policy coupled with EAP policy guidelines that allow for return to alcohol or drug problem treatment for EAP clients who relapse, on or off the job. Perhaps more common examples of policy inconsistency that may undermine compliance to a set of policies is where rank and file employees are governed by strict fitness-for-duty regulations, but professional and managerial employees

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drink at lunch, perhaps even in company dining rooms. Although this is commonly rationalized as a perquisite accompanying high status or as a necessity in entertaining clients, it creates inconsistencies in employee culture that may, for example, undermine support for an EAP policy. On a somewhat different plane is the issue of integrating policies that appear to have parallel intents. The work reported in this book by Shain and associates (chapter 11), as well as that of Foote (chapter 15), and Erfurt (chapter 18), has repeatedly underlined the potential for health promotion and wellness programs in addressing employee alcohol problems. Without repeating their observations, it is evident that a general organizational problem may affect the integration of wellness and EAP strategies. This problem is twofold, in part reflecting the very different program ideologies between those who advocate and/or operate wellness programs and EAPs, and in part reflecting competition between wellness and EAP efforts for both "turf" and scarce resources within the workplace. The ideological conflicts may be best illustrated by caricatures of the most extreme positions. Ardent wellness advocates bewail the costs and losses incurred with the EAP focus on employee alcohol problems that have already come to some level of fruition. They see such program emphases as "picking up the pieces" after disruption and potential disability have been allowed to run their natural course. These programmers have a high degree of confidence in their skills at encouraging healthy lifestyles, facilitating the adoption of behavioral alternatives to the stress-reducing payoffs of drinking, and thereby either directly or indirectly altering employee drinking behavior. These interventions are seen as much cheaper than EAP counseling or treatment. Further, the promotion of wellness is seen as producing desirable side effects such as better health and well-being as well as lower health benefit usage, in many instances independent of impacts on drinking behavior. From this extreme perspective, it is clear that there is a potential for wellness programmers to have little respect for EAP work. The extreme EAP ideological position is that wellness programming can have little impact on significant alcohol problems of employees because the genesis of these problems is biological and thus beyond the scope of any current prevention mechanism. Although those holding this extreme position may concede that wellness programs may affect some forms of employee drinking behavior, such impact is viewed as occurring in a target group that is different from that of the EAP. In other words, in the category of alcohol problems, wellness programs are seen as helping the already healthy rather than the potentially sick. From this perspective, wellness programs are viewed as based totally on voluntary behavior and self-selection, thus lacking the internal "clout" that an EAP might provide through the identification of problem job performance and the implementation of constructive confrontation. In reality, there are few programmers who articulate respective ideological positions of these extremes. The unfortunate upshot, however, is found in chapter 11 by Shain, namely the rarity of what he calls "high alcohol content health promotion programs." This would support the conclusion that wellness pro-

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grammers do not focus much of their resources on employee alcohol problems, but instead "concede" this problem area to EAPs. This is certainly a mechanism for avoiding repeated collisions of the differing program ideologies. It is rare to find wellness and EAP programs that work together in a cooperative and "synergistic" way. Recent work based on a national sample of organizations with wellness programs (Blum, Roman, and Patrick, 1990) indicates that there are some mutually supportive elements between the two types of programs, but such synergism is by no means strong. Our own on-site observations indicate that when both wellness and EAP efforts are present, they are rarely integrated and indeed may be viewed as conflictual and competitive. Such structural conditions can be seen as stemming from the failure to include workplace programming to deal with employee alcohol problems in organizations' strategic human resource planning efforts. Within such organizational planning, the interrelated functions of different efforts are clearly considered, and the possibility of collaborative support between wellness and EAP efforts is not a matter of wishful thinking, but of deliberate design. Thus if organizational decision makers desire a "high alcohol content" wellness program, it becomes a programmatic direction rather than hoped-for synergism between efforts that have become autonomous by default. ASSESSING PROGRAM OUTCOME The evaluation of EAPs and other alcohol-problem intervention strategies in the workplace remains relatively undeveloped. Especially challenging is the assessment of programs that are intended as primary prevention, that is, intervening such that the visible occurrence of alcohol problems is reduced. It is clear that a major challenge to such assessments is a proper baseline against which comparisons can be made. Obtaining valid data on the prevalence of alcohol problems in a work force is extremely difficult; the use of surveys within an organizational population to assess the presence of self-reported behaviors that are known to be defined as deviant by the employer is obviously problematic. It is possible to obtain partial assessments through looking only at outcomes, such as comparing the rates of referral of employee alcohol problems to an EAP before and after a particular new program or intervention has been introduced, or examining rates of usage of external counseling or treatment services before and after a new program's introduction. There are at least three difficulties with these outcome-oriented assessments, although their use is often preferable to no attempt at assessing impact. First is the obvious problem that without a baseline of problem prevalence, the data offer no insight into the extent to which the workplace's total employee alcohol problems are being dealt with. Second, such an outcome-oriented strategy includes the implicit assumption that alcohol problems that are not affected by a primary prevention strategy will "get worse" to the point that an intervention is called for. Thus these types of outcome-oriented strategies miss those instances

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where natural remissions have occurred, but where the preventive intervention may have reduced the impact of an employee alcohol problem during its acute phase. Third, this type of assessment cannot control for other factors in the environment that may have affected the outcomes, that is, forces beyond the scope of the prevention program may have increased or decreased the incidence (new events) of alcohol problems, changes in benefits may have created barriers to the use of the EAP or external counseling resources, or changes in perceived job security may have increased employee reluctance to use employer-sponsored services if such usage is seen as affecting job security. At first blush, it would appear that the evaluation of EAPs is considerably more straightforward and less problematic. Evaluation has, however, remained both problematic and underdeveloped. A major reason was an EAP marketing strategy that was dominant in the early 1970s (Roman, 1988), which emphasized the highly favorable cost-benefit ratio that could be produced by employers' investments in EAPs. Some of this promotion went so far as to pose EAPs as potential organizational profit centers. The forms of cost-benefit analysis used in this marketing were typically naive in both their designs and their claims, but they invited challenges from those in workplaces with some sophistication in assessing costs and benefits. As time went on and EAPs were established, it became clear that proof of cost-benefits was not essential for organizations to maintain their EAPs and that the cost-related criteria centered on accountability for the use of resources rather than bald demonstrations of saving money for the workplace. To a considerable extent (and with a notable exception described below), the cost-benefit basis of EAP evaluation tended to fade through the 1980s. There are some very important differences between the assessment of programs intended to reduce or eliminate particular events, and those such as EAPs that are designed to deal with problems already in evidence. As pointed out in this book, EAPs may produce primary preventive impacts (e.g., reduce the incidence of new alcohol problems), but the typical modes of assessment do not tap these potential impacts. Given EAP design, however, such impacts (if indeed they do occur) should be viewed as "spinoffs" or secondary effects because they are not the impacts that EAPs are designed to produce. The typical evaluations of EAPs do, however, tend to underestimate and cloud their organizational impact. Practically all evaluations that are reported focus on the magnitude of the caseload. This emphasis reflects the clinical backgrounds and orientations of a substantial proportion of EAP practitioners. But it is problematic for several reasons. First, it has the obvious problem of lacking a baseline of actual problem prevalence, an issue typically sidestepped by using gross estimates of baselines and then reporting an assumed "penetration rate." Second, most of these caseload statistics do not include breakdowns of the seriousness of the alcohol problems referred to the EAP. This information can

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be important in indicating the value of the EAP to the workplace to the extent that there is evidence that serious matters of supervisory management and problems of employee welfare are being addressed and, in some or many instances, successfully resolved. Such data can comprise a two-edged sword, however, for evidence of substantial proportions of early-stage cases may indicate that laterstage cases are remaining submerged within work groups and other protective organizational processes, whereas evidence of substantial proportions of laterstage cases may indicate that employee alcohol problems are escaping early identification. Third, and of considerable importance, few EAP assessments provide information on the extent of the staff effort involved in consultation with supervisors and union representatives in providing guidance in policy implementation or advice about the management of complex situations involving troubled employees. Such reduction of managerial headaches may be "worth their weight in gold" to the workplace, to the extent that supervisors are effectively aided in detaching themselves from personal and interpersonal difficulties and allowed to focus on their work duties. Finally, only a very small number of reported EAP assessments include data on the benefit usage patterns of clientele. Recently, however, research has been reported that provides a definitive answer to the impact of EAPs on benefit usage and also provides a landmark economic justification for their role in containing health costs (Mahoney and Smith, 1989). This study, conducted by the accounting firm of Alexander and Alexander within the McDonnell Douglas Corporation, included extensive review of benefit usage data for both EAP users and carefully selected "control" groups. The data confirm the economic value of EAPs in dramatically and significantly reducing the health care costs of employees with substance abuse and with psychiatric-emotional problems when the EAP was utilized to direct the affected employees to treatment services and follow them in the workplace after treatment. These impacts on health care utilization also applied to the dependent families of the employees.The research provided an estimate of a $5 million cost saving associated with the EAP over a three-year period, an estimate that the consultants regarded as conservative because it did not include measures of savings associated with the employees' improved job performances. Despite the recent flurry of interest and activity that has emerged around the issue of "managed health care," it is crucial to point out that the management of health care costs related to substance abuse treatment is not necessarily what needs to be "added on" to existing EAP practices. Indeed the function of health health care cost containment has been a basic mission of EAPs since their earlier days and predates much of the current concern. One of the dimensions of EAP "core technology" described in chapter 10 by Blum and Bennett is the linkage of the employee to the most appropriate treatment or counseling resource in the community, as well as providing interorganizational linkages between the EAP's

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home organization and community care providers such that the workplace became a more "informed consumer" of the treatment services it was purchasing either directly or through third-party payers. In reality, our field observations indicate that most alcohol-problem interventions in the workplace are evaluated on the basis of significant anecdotes (employees whose performance or whose pattern of benefits usage has been dramatically improved through use of the program) and on the basis of face validity (the effectiveness of the strategy is accepted because its design simply "makes sense"). Another general observation is that except for the ubiquity of caseload statistics, the evaluations that are completed are idiosyncratic to particular programs and settings. There are many important questions about the relative effectiveness of different strategies and their application in different types of work settings. Rather than calling for an accumulation of individual program evaluations, it is more appropriate to call for more research where external investigators are able to obtain the cooperation of a representative sample of organizations within which different programming strategies are operative. Having no data about effectiveness is certainly problematic, but having data that can be generalized only to workplaces very similar to the sites where data are collected may be detrimental. At the present time, the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse have funds to support a wide range of scientifically sound research investigations on interventions in the workplace related to substance abuse. Because many of those with clinical backgrounds in EAP work have had work experiences in public agencies where program evaluation was accorded a great deal of importance, there may be an exaggerated emphasis on the importance of systematic evaluations that should be associated with every organizationally based alcohol problem intervention program. One may seriously question the value or priority of the investment of scarce resources in such assessments without a defined need for such information and without the background to carry out well-designed data collections or analyses. In contrast, there is no doubt of the importance of maintaining thorough and adequate recordkeeping in association with these programs, allowing for the program's accountability for the resources that it utilizes as well as providing the potential for answering management's or union leaders' questions about aspects of the program's operations should internal or external contingencies produce such data needs. Having such data is especially crucial when the future planning of a program requires the addition of staff and/or resources, neither of which can typically be justified on the basis of anecdotes or heart-felt pleas. Further, the maintenance of program data may allow the merging of such information for research studies that involve multiple organizational settings and that may offer scientifically sophisticated answers to questions about program effectiveness that can be generalized across a variety of program settings.

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SUSTAINING INVESTMENTS IN INTERVENTIONS An emerging consideration of great importance for employers to obtain a full "return" on their investment in measures to deal with employee alcohol problems is "follow-up," the continuing attention and support following treatment and for the period of recovery, which indeed may be life-long. As described in chapter 18 by Erfurt, follow-up is an extremely important preventive consideration. Unfortunately, the notion of follow-up is frequently interchanged with the concept of "aftercare," which is an extension of the treatment experience into the period after the termination of active inpatient or outpatient care. Whereas aftercare may be viewed as primarily therapeutic in nature and focused on individual patients' skills at dealing with their inner feelings and reactions to others, follow-up is focused on the role responsibilities that recovering alcoholic individuals must successfully execute in everyday life if recovery is to have longterm social and economic consequences for their well-being. Viewed somewhat differently, aftercare may be defined as reducing an individual's possibility of relapse; follow-up may be defined as reducing the tolerance of relapse within the social groups of which the individual has role responsibilities, coupled with systematic monitoring of the individual within these networks. This distinction may seem overly academic, but one very important distinction is that follow-up does not necessarily require the professional clinical skills indicated by aftercare. Follow-up at the workplace is obviously facilitated by the presence of an EAP, and follow-up should be a priority responsibility of EAPs. Yet, with much lip service given to the importance of follow-up, it is evident that many employers who have invested in EAPs and who are indirectly providing alcoholism treatment for employees have invested little in means for assuring that the impacts of the treatment experience are sustained. Some of this neglect had roots in dynamics that are essentially organizational. In many settings, follow-up is neglected because it is assumed that such services are the responsibility of the agency that provided the treatment. It is evident that the interplay between treatment and workplace bureaucracies usually precludes the successful interpenetration of the treatment organization into the work organization, even if this is attempted. At the same time the demands for predictability in resource allocation in the operation of treatment centers is such that an open-ended commitment to client follow-up is rarely a realistic possibility, even though it may be unrealistically promised. Another dimension to the follow-up issue is that too often the processing of alcohol cases within EAPs operates from a traditional medical model where it is assumed that successful treatment is synonymous with successful recovery. Such an assumption is not unusual with the treatment of many medical conditions, where the likelihood of relapse or reoccurrence of the disorder is not high. Many

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clients leave alcoholism treatment in a state of high enthusiasm and apparent commitment to their recovery, offering what appears as sound evidence of successful treatment. Given the insidious nature of relapse and the different risks that recovering individuals face as the recovery process develops over time, such evidence may be very misleading. In instances of medical care where there is a possibility of relapse when patients do not adhere to the behavioral advice given to them during treatment, it is almost universally assumed that it is the patient's reponsibility to follow such advice to sustain recovery. The basic philosophy of this assumption is central to workplace EAP strategies in that such programs must always sustain the principle that the primary commitment to sustaining adequate job performance must lie with the individual employee. It is clear, however, that a blind following of this principle without providing the recovering alcoholic employee with follow-up support may be foolhardy. The nature of addictive behavior is such that the probability of relapse and loss of much of the employers' investments in treatment is high without systematic follow-up. Although attention to follow-up of employees treated for alcohol problems is relatively new, the conclusion must be drawn at present that the employer, through the EAP, must take responsibility for follow-up if it is to be effective. Analogies are dangerous, but it is clear that most employers would continue to attend to a valuable piece of equipment that had become inoperative and had required an extensive maintenance investment. The same may apply to those employees in whom an extensive investment in treatment has been made. Little is yet known in a systematic way about the efficacy of follow-up across different work settings and across different patterns of EAP organization, but impressionistic evidence indicates that the decline in relapse and the maintenance of treatment gains can be dramatic with the employer's relatively modest investment in the long-term follow-up of employees who have been treated for alcohol problems. NOTE Partial support during the preparation of this manuscript and book from Grants No. R01-AA-07218,R01-AA-07250, and T32-AA-07473 awarded by the National Institute on Alcohol Abuse and Alcoholism to the University of Georgia and to Georgia Institute of Technology is gratefully acknowledged.

REFERENCES Amaral, T., and Cross, S. (1988). Cost-benefits of supervisory referrals. In Proceedings of the research track of the 17th annual conference of the Association of Labor and Management Administrators and Consultants on Alcoholism (pp. 24-33). Arlington, VA: ALMACA. Blum, T.C. (1989). The presence and integration of drug abuse interventions in human resource management. In S. Guste and M. Walsh (Eds.), Drugs in the workplace:

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Research and evaluation data, National Institute on Drug Abuse Research Monograph No. 91. Washington, DC: U.S. Government Printing Office. Blum, T . C , and Roman, P.M. (1987). Choices between internal and external employee assistance programs. In Sarah Crim (Ed.), Employee assistance programs in the workplace (pp. 95-104). Washington, DC: Bureau of National Affairs Press. Blum, T . C , and Roman, P.M. (1989). Employee assistance programs and human resources management. In K.M. Rowland and G.R. Ferris (Eds.), Research in personnel and human resources management (Vol. 7, pp. 259-312). Greenwich, CT: JAI Press. Blum, T . C , Roman, P.M., and Patrick, L. (1990). Synergism in the adoption of employee assistance and health promotion programs. Journal of Occupational Medicine, 50. Bray, R., Marsden, M., Guess, L., Wheeless, S., Pate, D., Dunteman, G., and Ianacchione, V. (1983). 1982 worldwide survey of alcohol and nonmedical drug use among military personnel. Research Triangle Park, NC: Research Triangle Institute. Bray, R., Marsden, M., Guess, L., Wheeless, S., Pate, D., Dunteman, G., and Ianacchione, V. (1986). 1985 worldwide survey of alcohol and nonmedical drug use among military personnel. Research Triangle Park, NC: Research Triangle Institute. Cahalan, D., and Room, R. (1974). Problem drinking among American men. New Brunswick, NJ: Rutgers Center of Alcohol Studies. Chapman, E. M. (1990). The supervisor's survival handbook (5th ed.). New York: Macmillan. Guste, S., and Walsh, M. (Eds.). (1989). Drugs in the workplace: Research and evaluation data, National Institute on Drug Abuse Research Monograph No. 91. Washington, DC: U.S. Government Printing Office. Mahoney, J., and Smith, D. (1989). McDonnell Douglas Corporation's EAP produces. The ALMACAN, 19 (8), 18-26. Molloy, D. (1989). Peer intervention: An exploratory study. Journal of Drug Issues, 19, 319-329. Mooney, C J. (1989). Feeling disillusioned? Unappreciated? You may be a victim of what a psychologist describes as 'professorial melancholia.' Chronicle of Higher Education, 36 (12), A13-A14. National Institute on Alcohol Abuse and Alcoholism (1990). The seventh annual report to the U.S. Congress on Alcohol and Health. Washington, DC: U.S. Government Printing Office. Pattison, E.M., and Kaufman, E.S. (Eds.). (1982). The encyclopedic handbook on alcoholism. New York: Gardner Press. Roizen, R., Cahalan, D., and Shanks, P. (1978). 'Spontaneous remission' among untreated problem drinkers. In D.B. Kandel (Ed.), Longitudinal research on drug use (pp. 197-224). New York: Hemisphere/Wiley. Roman, P.M. (1970). The future professor: functions and patterns of drinking among graduate students. In George L. Maddox (Ed.), The domesticated drug: Drinking among collegians (pp. 204-217). New Haven: College and University Press. Roman, P.M. (1974). Settings for successful deviance: Drinking and deviant drinking among middle and upper level employees. In Clifton D. Bryant (Ed.), Deviant behavior: Occupational and organizational bases (pp. 109-128). Chicago: Rand McNally.

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Roman, P.M. (1982). Barriers to the development of employee alcoholism programs. In A.A. Pawlowski (Ed.), Occupational alcoholism: A review of research issues (pp. 139-177). Washington, DC: Government Printing Office. Roman, P.M. (1988). Growth and transformation in workplace alcoholism programming. In Marc Galanter (Ed.), Recent developments in alcoholism (Vol. 6, pp. 131158). New York: Plenum Press. Roman, P.M. (1989). The use of employee assistance programs to deal with drug abuse in the workplace. In S. Guste and M. Walsh (Eds.), Drugs in the workplace: Research and evaluation data, National Institute on Drug Abuse Research Monograph No. 91 (pp. 271-286). Washington, DC: U.S. Government Printing Office. Roman, P.M., and Blum, T.C (1984). Alcohol, pampering and the rise to social stardom. Contemporary Drug Problems, 12, ll'i-lAl. Roman, P.M., and Trice, H.M. (1970). The development of deviant drinking behaviors: Occupational risk factors. Archives of Environmental Health, 20, 424-435. Sonnenstuhl, W.J., and Trice, H.M. (1987). The social construction of alcohol problems in a union's peer counseling program. Journal of Drug Issues, 17, 223-254. Straus, R. (1976), Alcoholism and problem drinking. In R. Merton and R. Nisbet (Eds.), Contemporary social problems (4th ed., pp. 183-217). New York: Harcourt, Brace, Jovanovich. Trice, H.M., and Belasco, J.A. (1970). The aging collegian: Drinking pathologies among executive and professional alumni. In George L. Maddox (Ed.), The domesticated drug: Drinking among collegians. New Haven: College and University Press. Voss, H. (1989). Drug use patterns and demographics of employed drug users: Data from a national household survey. In S. Guste and M. Walsh (Eds.), Drugs in the workplace: Research and evaluation data, National Institute on Drug Abuse Research Monograph No. 91. Washington, DC U.S. Government Printing Office.

INDEX Alcohol: age, and alcohol problems in workplace, 20; age, and influence on social attitudes, toward alcohol, 21-22, 372-73, 377; attitudes toward, and age, 22; attitudes toward, in the workplace, 261-64; attitudes toward, social, 261-63, 266-68, 363-65; consumption, 168-70; policy, in workplace, 24, 40, 101-3, 372-74; social problems of, 2-3 Alcoholism: alcoholics, identification of, 126-29; alcoholics, types, 29; medical model, 135, 265-66, 328; prevalence of among employed, 45-46, 129-31; programs, 39-41; self-control impaired over alcohol, 29; trends in services, 135-36 BITE (Behavioral Index of Troubled Employees): attitudes toward EAP, 21213; characteristics of problem employees, 211-12. See also EAP; Jobs Bystander-equity model: explanation of, 208; future research, 213-19; future research, directions for worksite research, 218-19; future research, family, 216-17; future research, substance abuse employees, 213-14; future re-

search, supervisory and worksite characteristics, 214-15; future research, troubled women, 215-16; research on, 211-13. See also Corporate social responsibility; EAP; Jobs; Work; Workplace Corporate social responsibility, 4, 19798. See also Jobs; Work; Workplace EAP (Employee Assistance Program): accessibility of, 253-55, 390-91; accountability, 391-92; control, 389-90; core technology, 39-40, 145-47, 4 0 1 2; core technology, in integration, 156-59; employee well-being, family, 198-200; employee well-being, stress, 183-85; evaluation, 206-7, 297-98, 301-4, 307-8, 399-402; evaluation, approach, 308-11; evaluation, managerial perspective, 304-6; flexibility, 391; follow-up, 277-78, 283-84, 287-89, 403-4; functions and goals, 10-12, 144-45, 151-53, 185-88, 204-6, 22829, 299-301, 311-12, 352-53, 373, 393-95; future of, 134-35, 207-8; implementation, 181-83, 229; integration, 153-55, 389, 397-99; internal/external,

408 386-89; intervention, 191-92, 195-96, 229-30, 232-34, 238-41; organizational consultant, 185-88, 231; organizational culture, 392-93; overview, 6 8, 237-38; political taboos, 289-90; prevalence of, 147; prevention, 14344, 159-61, 217, 278-80, 380; self-referral, 394-97; supervisor training, 157-59, 217-18, 230-32, 251-53, 352-53, 394; types, 8-10, 144; utilization, 149-51, 158, 350-52; utilization, research, 349-50 Economy, impact on alcohol problems, 19-20 Employed adults at risk for loss of control over alcohol use, 27, 41. See also Employment; Jobs; Work; Workplace Employment: and alcohol use, 45, 96-99, 129-31; and risk for loss of control over alcohol use, 27-41, 99-100 Help processes, social distance, 249-50. See also Social networks; Treatment Help-seeking: social pressure, 242-45; stages of, 246-58. See also Social networks; Treatment HPPs (Health Promotion Programs): coordination with EAP, 166-67, 172-74, 176-77, 398; effects on drinking, 16768; implementation, 171—72; movement, 22-23; prevalence, 164-67; prevention, 170. See also EAP; Jobs; Wellness programs; Work; Workplace Intervention: aftercare, 277-78; early, social supports, 193-96, 241-42; suggested research, 72-74, 340-43; in workplace, 40-41, 60, 78-79; in workplace, constructive confrontation, 34043; in workplace, factors influencing, 4-6, 107-9. See also EAP; Jobs; Prevention; Work; Workplace Jobs: alcohol-related problems, 97-100, 131-32, 379-80; alcohol-related problems, age, 20; burnout, medical students, 68-72; burnout, in relation to alcohol use, 35-38; burnout, women,

Index 116-17; related influences on alcohol use, 47-49, 54, 80-81, 365-66, 37879; related influences on alcoholic use, prescriptive/proscriptive norms, 9 9 100, 119-20; stress and alcohol use, 50-54, 57-58, 99-100, 347-48, 37778, 380; stress and alcohol use, medical students, 68-72; stress and alcohol use, women, 34-35, 113-16, 120 Legal changes and effect on employee dismissal, 4-5 Marketing services, 4; in relation to workplace, 320-23. See also EAP; Treatment Medicalization of behavioral problems, 4-6, 135. See also Alcohol; Alcoholism OAPs (Occupational Alcoholism Programs). See EAP Occupational subcultures: analyses of, 79-80, 83-92, 98-99, 344-45; differences between, 80-81, 381-83; variables, 82-83. See also Employment; Jobs; Work; Workplace Occupations. See Jobs Prevention, 74, 367-68; concepts, systems approach, 366-67; follow-up, 278-80, 284-85; primary, 292; tertiary, EAP's, 287-88; tertiary, wellness programs, 286-87; in workplace, 78-79, 362-63, 367, 380. See also EAP; Intervention Public policy, alcohol policy in workplace, 24 Smoking: and environmental movement, 23; and implications for alcohol policy, 23-24; wellness programs, 281-82. See also Wellness programs Social networks: alcohol use in, 103-4, 345-46, 381; heavy drinkers, 104-6; moderate drinkers, 106-7; women, 117-18. See also Jobs; Work; Workplace

Index Technological changes, impact on employee, 4 Treatment: center study, 317-19; cost, 328-29; relationship to workplace, 74, 316-17, 319-22, 329-31; responses to workplace demands, 323-24, 331-33; social control programs, 136-37. See also EAP; HPP; Marketing services; Wellness programs Wellness programs: follow-up, 281-84, 292; political taboos, 290-92; relationship with EAP, 234, 292-95, 398. See also EAP; HPP Work: alienation and alcohol, 27-29, 3 3 35, 49-50, 56-57, 99-100, 270-71, 346-47; alienation and alcohol, psychological, 32-33; alienation and alco-

409 hol, structural, 30-31. See also Alcohol; Jobs; Occupation; Workplace Workplace: alcoholism programs, 3-4, 39-40; alcoholism programs, factors influencing, 4-6, 373; alcohol policy in, 24, 40, 101-3, 372-74, 378-79; alcohol problems, epidemiology of, 4647, 77-79, 362, 384-85; alcohol use due to, 36-38, 82-83, 92, 97-98, 100-101, 108, 343-44; consumption, women, 55, 115-16, 118-19; drug/alcohol screening, preemployment, 37577; history of alcohol, 95-97; labor unions, alcohol prevention, 382-83; related research, 134, 214-16, 368-69; work-family conflicts, 385-86. See also Alcohol; EAP; Jobs; Occupation; Work

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ABOUT THE CONTRIBUTORS GENEVIEVE AMES, Study Director and Senior Research Scientist, Prevention Research Center, Berkeley, CA NATHAN BENNETT, Assistant Professor, Department of Management, Louisiana State University, Baton Rouge, LA LISA K. BLOCK, Research Coordinator, Institute for Behavioral Research, University of Georgia, Athens, GA TERRY C. BLUM, Associate Professor, College of Management, Georgia Institute of Technology, Atlanta, GA JOHN C. ERFURT, Associate Research Scientist, Institute of Labor & Industrial Relations, University of Michigan, Ann Arbor, MI GAIL C. FARMER, Assistant Professor, Department of Sociology, California State University at Long Beach, Long Beach, CA KAYE MIDDLETON FILLMORE, Adjunct Associate Professor of Sociology, Institute for Health & Aging, University of California at San Francisco, San Francisco, CA WILLIAM J. FILSTEAD, Director of Program Research & Evaluation, Parkside Lutheran Hospital, Park Ridge, IL ANDREA FOOTE, Associate Research Scientist, Institute of Labor & Industrial Relations, University of Michigan, Ann Arbor, MI

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About the Contributors

LAWRENCE H. GERSTEIN, Associate Professor, Department of Counseling Psychology, Ball State University, Muncie, IN BRADLEY GOOGINS, Associate Professor, Graduate School of Social Work, Boston University, Boston, MA FRANK GUGLIELMO, Adjunct Lecturer, Department of Psychology, Baruch College, City University of New York, New York, NY HAROLD D. HOLDER, Scientific Director/Senior Research Scientist, Prevention Research Center, Berkeley, CA CRAIG JANES, Assistant Professor, Department of Anthropology, University of Colorado, Denver, CO JACK K. MARTIN, Postdoctoral Associate, Institute for Behavioral Research, University of Georgia, Athens, GA JANET S. MOORE, Postdoctoral Associate, Institute for Behavioral Research, University of Georgia, Athens, GA HAROLD A. MULFORD, Director of Alcohol Studies and Professor, Department of Psychiatry, Iowa State Psychopathic Hospital, University of Iowa, Iowa City, IA DOUGLAS A. PARKER, Professor, Department of Sociology, California State University at Long Beach, Long Beach, CA LINDA F. PATRICK, Postdoctoral Associate, Institute for Behavioral Research, University of Georgia, Athens, GA DAVID J. PITTMAN, Professor, Department of Sociology, Washington University, St. Louis, MO WALTER REICHMAN, Professor, Chairman, Department of Psychology, Baruch College, City University of New York, New York, NY JUDITH A. RICHMAN, Assistant Professor, Department of Psychiatry, University of Illinois Medical Center, Chicago, IL PAUL M. ROMAN, Professor of Sociology and Center Director, Institute for Behavioral Research, University of Georgia, Athens, GA

About the Contributors

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MARTIN SHAIN, Head, Occupational Programmes Research, Addiction Research Foundation, Toronto, Ontario ELSIE R. SHORE, Assistant Professor and Director, Research Group on Women and Work, Department of Psychology, Wichita State University, Wichita, KS WILLIAM J. SONNENSTUHL, Director, Employee Assistance Education and Research Program, N. Y. State School of Industrial & Labor Relations, Cornell University, Ithaca, NY HARRISON M. TRICE, Professor, Department of Organizational Behavior, N.Y. State School of Industrial & Labor Relations, Cornell University, Ithaca, NY