Workplace Interventions for Drug Abuse: Part A

Annotated Bibliography
May, 1998

Paul D. Steele, Ph.D
University of New Mexico

Hyperlinks to sections within this text:

Part A:
Employee Assistance Programs
Prevention Programs

Part B:
Drug- and Alcohol-Testing Programs

EMPLOYEE ASSISTANCE PROGRAMS

Bacharach, S., Bamberger, P., & Sonnenstuhl, W. (1994). Member assistance programs in the workplace: The role of labor in the prevention and treatment of substance abuse. ILR Bulletin, 69 (88 pages). Ithaca, NY: ILR Press.

The authors examine the roots of member assistance programs (MAPs) in communal voluntarism. They present several program examples to show how MAPs can deter substance abuse at work, motivate union members to seek help for their problems, and help recovering workers maintain long-term abstinence. Successful MAPs deter substance abuse by helping workers save their lives and livelihoods; by providing union members with explicit definitions and expectations concerning drinking on the job; by viewing referral and long-term follow-up as part of a total approach to substance abuse prevention and deterrence; by challenging traditional occupational or organizational cultures characterized by denial and cover-up and enabling them to transform themselves into cultures characterized by their members’ sobriety; and by acting as agents of cultural change. MAPs use several approaches to motivate troubled union members to seek help, including developing trust based on a sense of common occupational and social identities, placing a high priority on confidentiality, helping with a broad range of personal problems while staying especially sensitive to the problems of alcohol and other drugs, providing information and treatment alternatives, making referrals to appropriate services, encouraging workers to manage their problems over the long term with the aid of self-help groups, and monitoring the effectiveness of and expanding their list of treatment options.

MAPs are most effective when they are well implemented. They require ongoing training of peer counselors, and workers must constantly be made aware of the existence and functions of the program. The authors recommend the establishment of MAPs by government, management, and labor as a means for making the marketplace for health services more competitive; they are cost-effective and work to personalize the highly bureaucratic prevention, referral, treatment, and follow-up health care infrastructure. The authors also recommend redefining the workplace culture to encourage peer participation, particularly in support of long-term management of substance abuse.

Backer, T. (1991). Drug abuse services and EAPs: Preliminary report on a national study. National Institute on Drug Abuse, Drug abuse services research series, No. 1: Background papers on drug abuse financing and services research (pp. 227-244). Rockville, MD: U.S. Department of Health and Human Services.

This article reports on the results of the National Study of Workplace Drug Abuse programs, initiated in January 1987. The study’s objectives are to develop data-based typologies of employment assistance program (EAP) drug abuse services and the organizational contexts in which they occur and to identify and study emerging issues that will affect the development of services. In Phase I, survey data collected by questionnaire from EAP coordinators and program administrators were compiled on 1,238 EAPs. The database focuses exclusively on drug abuse services and excludes coverage for alcohol problems. Phase II of the research involved 201 intensive telephone interviews with EAP coordinators selected at random from Phase I survey respondents.

Of responding EAPs, 47.2% were internal, 40.8% were externally contracted services, 8.8% were consortia EAPs, and 3.3% were union-sponsored programs. Both public- and private-sector programs were included in the survey. The majority had been established in the previous 5 years, and most were based in or affiliated with human resource departments. Marijuana and cocaine were the drugs most often reported as used by EAP clients, although polydrug use was quite common. Approximately three-fourths of the programs see fewer than 10 drug-abusing clients per month. EAPs are very inconsistent in taking drug histories of clients. Three-fourths of the respondents stated that their company has a written drug abuse policy, and 35% have a drug-testing program. About one-half of programs felt extremely supported by management, and 35% felt somewhat supported. Respondents indicated most often that there was an EAP in the company to help troubled employees, to serve as an employee benefit, to relieve supervisors of problem workers, and to engage in health care cost containment, respectively.

Only about one-third of respondents believed that EAP drug intervention was very (8.4%) or fairly (26.1%) effective, whereas almost one-half believed that it was limited in effectiveness (37.0%) or not very effective (10.7%). Perceptions of effectiveness of the EAP were positively influenced by the presence of a work site drug-testing program. EAPs were likely to operate in work sites that engaged in managed care practices, the most prevalent being case management, HMO, chemical dependency relationship, preferred provider organization, and benefits certification, respectively. Management training was considered to be a primary responsibility and priority of EAP respondents. Respondents from smaller work sites (fewer than 500 employees) were less likely to believe that the EAP was effective in fighting drug abuse, to have a written policy or drug-testing program, to have experienced litigation related to the EAP or drug-testing program, or to have had problems with drug sales at work than large workplaces (greater than 10,000 employees).

Respondents indicated that the most important challenges were getting HMOs to provide adequate drug services, dealing with public safety issues, and providing an effective continuum of care. Adequacy of insurance coverage, cost containment, and training were also considered to be significant challenges. Respondents indicated that they would be best helped in meeting these challenges by changes in attitude by top management, increased education for supervisors, improvement of insurance and benefits, and more resources for the EAP.

Bamberger, P., & Sonnenstuhl, W. (1995). Peer referral networks and utilization of a union-based EAP. Journal of Drug Issues, 25, 291-312.

This article is written for a readership of practitioners and researchers. The authors point out that peers in the workplace play an important role in attitudes about the EAP, referrals, and program utilization. However, the impact of peer friendship and union networks has not been systematically studied. The authors engaged in an ethnographic study of 17 (out of a universe of 23) local committees of the Association of Flight Attendants Employee Assistance Program (AFA EAP) in 12 cities in the United States. Data collection involved interviews with AFA EAP members and management, participant observation of peer training sessions, and review of archival data. Data were analyzed using the constant comparative method. The authors have inductively derived and provided provisional support for four hypotheses concerning the role of peer referral networks: (a) The larger the network of friends and supporters, the greater the percentage of total chemical dependency cases identified by the local EAP committee. (b) As the quality of perceived local-level labor-management relations improves, chemical dependency utilization rates will increase. (c) The more embedded the EAP is in the multiple networks that make up the union, the greater will be the overall utilization rate. (d) The more strongly the union-based EAP endorses a positive belief in the ability of coworkers to recover from substance abuse problems, the greater will be the percentage of chemical dependency cases.

Bennett, N. (1989). Stress among employee assistance program administrators: The influence of role and organizational characteristics. Journal of Drug Issues, 19, 403-418.

This paper examines the relationship between role characteristics, organizational characteristics, and stress in a sample of employee assistance program administrators. In addition, variables that the organizational literature suggests "buffer" the relationship of antecedents with stress are considered. Interview data collected from 246 EAP administrators, as a part of a larger study conducted in 1984-1985, were analyzed. Scales of independent (autonomy, task variety, work structure, openness to information flow), intervening (organizational resources), and dependent (job-related tension/stress) variable constructs were developed, and specific indicators were refined. The results indicate that status, autonomy, structured work, and an unrestricted flow of information were all negatively associated with stress. Task variety was positively associated with stress. In addition, buffering variables were significantly associated with stress. Specifically, top management support and organizational resources were negatively associated, whereas high levels of job involvement were positively associated, with stress. The author suggests that these findings are significant, since several of the variables are within the organization’s control and, as such, can be altered. He states that organizations concerned about the stress felt by EAP administrators might reduce it by providing more autonomy or opening channels of communication between administrators and their organizational constituents. Further, clearly stated support from top management could be expected to make a program administrator’s job less stressful.

Blum, T., & Roman, P. (1988). Purveyor organizations and the implementation of employee assistance programs. Journal of Applied Behavioral Science, 24, 397-411.

Employee assistance programs have proliferated rapidly, but few studies have examined the processes of this diffusion. Of those, most have focused on the organizations that have adopted EAPs. This article describes the purveyor organizations that market EAPs. The authors hypothesize four relationships between characteristics of the purveyor organization and the extent of EAP implementation. First, implementation is positively associated with the integration of and resources available for the EAP subunit within a purveyor organization. Second, implementation is positively associated with the level of managerial control over and monitoring of consulting personnel and all programming efforts. Third, implementation is positively associated with the number of supportive relationships a purveyor organization has with counseling and treatment organizations. Fourth, implementation is positively associated with the endorsement of community leaders in government, business, and labor. Using survey data from 724 occupational program consultants from purveyor organizations, the authors conducted a multivariate analysis. The findings support the hypotheses that these features of purveyor organizations affect the extent to which EAPs are implemented, with managerial control over the EAP subunit accounting for most of the variance.

Blum, T., & Roman, P. (1992). A description of clients using employee assistance programs. Alcohol Health and Research World, 16 (2), 120-128.

EAPs are an outgrowth of efforts of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to mainstream alcoholism treatment into the U.S. health care delivery system. The authors emphasize that the monitoring of employee behaviors by supervisors should be limited to issues of job performance and that supervisors should encourage the self-referral of employees for personal problems. Approximately 5% of employees working in an organization offering an EAP use it each year. In the past decade, EAPs have become a popular means for addressing worker problems. In this article, the authors update their description of the core technologies of EAPs and discuss findings of a study of clients (N = 6,400) served by EAPs in 84 work sites.

The authors group core technologies into those related to supervisory management and those involving the relationship between the EAP and benefits management. In the former group are the technologies of identification of employee problems through impaired job performance; consultation with managers, supervisors, and union stewards about troubled employees; and constructive confrontation. Those related to benefits management include microlinkages of employees with appropriate services, macrolinkages with treatment providers, and mainstreaming of alcohol-problem benefits in a culture supportive of alcohol problem prevention and intervention.

Survey data were collected by use of a questionnaire completed by EAP administrators concerning demographic information about each client who had made at least an initial contact with their program. The questionnaire also was used to collect information about referral categories, treatment history, clinical assessment, treatment regimen, and prognosis. In addition, EAP clients completed a questionnaire about their job functions and performance, satisfaction with relationships, and the roles of people who were influential in referral or utilization of the EAP. The client questionnaire also included items from the CAGE assessment instrument for alcohol problems and a short form of the Beck Depression Inventory.

The authors found that although all segments of the work force were represented in the EAP client group, women were more likely than men to use the program. In addition, whites were underrepresented in the EAP client group relative to their distribution in the work force of participating organizations. Clients indicated substantial depression, and 19% of clients indicated possible alcohol-related problems. EAP counselors diagnosed clients in an average of 2.1 problem categories, including psychological/emotional (43.7%), marital (28.1%), other family (30.9%), alcohol (15.9%), crack/cocaine (3.4%), and other drug (3.9%) problems. In addition, 21% of EAP caseloads were made up of clients who were troubled by the alcohol and other drug problems of their family members.

Male clients and those with lower educational levels were more likely to manifest alcohol problems; no significant difference by ethnic group was found. Blue-collar workers were most likely and clerical workers least likely to be assessed with alcohol problems. Job characteristics of working as an outside representative of the organization, working off the premises, traveling, working overtime, operating motor vehicles, using computers, expending physical effort, using heavy equipment, and having little customer contact were associated with alcohol assessments. This group was also more likely to have legal and work attendance problems.

Self-referral was less likely by clients with alcohol-related assessments, whereas formal, supervisorial referrals were twice as likely for this group than for those with other problems. Supervisors and spouses were more likely to have been influential in the referral process for those with alcohol assessments than for those with other problems. Women were less likely than men to be referred by supervisors. Whereas 13.6% of all clients were treated within the EAP (without referral to outside treatment providers), this was less likely for those with alcohol problems of their own. Of the latter group, 20% were referred for inpatient treatment, 5% to self-help groups, and the remainder to outpatient treatment.

Blum, T., Roman, P., & Patrick, L. (1990). Synergism in work site adoption of employee assistance programs and health promotion activities. Journal of Occupational Medicine, 32, 461-467.

As workplaces increasingly adopt proactive programs directed toward employee health issues, the interrelation between different programs becomes an important issue. This article discusses the synergy in patterns of program adoption between EAPs and health promotion activities (HPAs). Both EAPs and HPAs are centered on models of mutual benefits to both employers and employees (i.e., behavioral changes enhance individual health and well-being while fostering health care cost containment and productivity).

The authors analyze data from the 1985 National Survey of Worksite Health Promotion Activities (N = 1,358) to determine the co-occurrence of EAPs and HPAs. Results of a multivariate analysis suggest that synergy occurs, with EAP adoption appearing to influence HPA adoption to a greater degree than the reverse. It was also found that, in addition to several organizational variables, EAP presence and HPA presence are the best predictors of each other’s presence, although EAPs were four times more likely to predict HPAs than vice versa. Contrary to other findings, this data set yields no association between industry type and the presence of EAPs. The authors suggest that EAPs have been broadly diffused across a wide variety of workplaces. HPAs are less well integrated and accepted as workplace innovations. The authors recommend that HPAs engage in activities to attract their target audiences into program activities and define core technologies and parameters for their programs. EAPs and HPAs should not be forced to compete for scarce organizational resources and should work to maximize program cross-referrals.

Bray, J., French, M., Bowland, B., & Dunlap, L. (1996). The cost of employee assistance programs (EAPs): Findings from seven case studies. Employee Assistance Quarterly, 11 (4), 1-19.

According to the authors, few studies have systematically examined the costs of EAPs. This paper analyzes consistent and comparable cost data from case studies of EAPs in seven work sites. Because the same data collection instruments and methods were used to collect cost data at each work site, the data can be used to directly compare cost estimates across programs. Factors included in the study were personnel, operating, building, equipment, and utilities/supplies costs. The researchers also collected the opportunity costs of resources used free of charge and those shared with other departments. Researchers collected information concerning the number of employees eligible to use and the number who actually used the EAP. Data were collected from expenditure records (rather than from budgets).

The authors report that overall costs and their distribution depend on the service delivery characteristics of the EAP. Higher utilization rates consistently were associated with higher costs per eligible employee. EAPs demonstrate some economies of scale. The author found that labor costs account for the majority of EAP costs regardless of the services offered, and that EAPs with similar costs per eligible employee may use a substantially different mix of resources. The costs for EAP services computed for the seven case study sites are slightly greater than, but comparable to, national estimates of EAP costs.

Capece, M., & Akers, R. (1995). Supervisor referrals to employee assistance programs: A social learning perspective. Journal of Drug Issues, 25, 341-361.

This study examines variables related to supervisors’ decisions to refer substance-using employees to EAPs. It is directed to policy makers, practitioners, and social scientists interested in the application of the social learning perspective. Data collection consisted of the administration of a questionnaire to 90 supervisors employed by two general hospitals in the Southeast. Discriminant function analysis was performed on the supervisors’ responses. The authors conclude that reinforcement of the supervisors’ referral behaviors and the attitudes of others are strong predictors of subsequent referral behavior. Specifically, supervisors who anticipated the social approval of other supervisors and employees for referring a worker with alcohol or drug problems or self-referring for these problems were more likely to use the EAP. In addition, the degree to which supervisors perceived strong organizational support for the EAP is a strong predictor of EAP use. The practical implication of the study is that the organizational climate, as demonstrated by administrative support and employee definitions, is a strong predictor of a first-line supervisor’s willingness to personally use or to refer workers to the EAP. The authors suggest that organizational decision makers should work to promote a positive organizational image of the EAP, which should result in heightened referrals and utilization by supervisors.

Evans, B., & Trice, H. (1995). Acceptance and implementation of EAP core and noncore tasks. Journal of Drug Issues, 25, 379-396.

In this article, Evans and Trice build upon earlier research by Roman and Blum concerning the core tasks, or technologies, of EAPs. These tasks originally were publicized in a series of articles by Roman and Blum and were intended to describe the basic activities of professionals working in this field. Evans and Trice identify seven areas of EAP activity, including identifying employee behavioral problems based on job performance issues; providing expert consultation with supervisors, managers, or union stewards on how to take the appropriate steps in using employee assistance policy and procedures; appropriately using the constructive confrontation strategy; creating microlinkages with counseling, treatment, and other community resources; creating and maintaining macrolinkages between the work organization and counseling, treatment, and other community resources; maintaining a focus on employee alcohol and substance abuse problems (this strategy offers the most significant promise of improving future performance and reducing benefit usage); and serving as a consultant to the organization at large on issues of personal problems affecting employee welfare.

Evans and Trice report on empirical research with EAP workers concerning their acceptance and implementation of these tasks. They interviewed a 10% sample of Employee Assistance Professionals Association (EAPA) members in New York State and participants in an 18-credit EAP education program presented by Cornell University between 1985 and 1990. They content-analyzed open-ended responses from these subjects to derive empirically the scope of tasks performed by EAP workers. Their operational definition was consistent with Roman and Blum's categories, but it included other tasks that they thought were essential to EAP work not mentioned by those authors (e.g., maintaining client confidentiality). For purposes of research, they defined noncore tasks as those that are not central to the EAP's basic goal of identifying troubled workers based on deteriorating job performance and referring them to treatment.

Attitudes concerning the implementation of identified core and frequently mentioned noncore tasks were collected in a subsequent survey mailed to the original 238 study participants, with a return rate of 78.2%. A subsequent item reliability correlation test of several items resulted in a Time1/Time2 correlation of r = .7312.

Evans and Trice found core tasks were reported as more important to respondents than noncore tasks. However, the most important noncore task (training supervisors to recognize employees' clinical symptoms) had a similar median score to the least important core task (interfacing with insurance and other benefit management systems). They also found that six of the core EAP tasks (maintaining client confidentiality, establishing macrolinkages, maintaining an alcohol focus, assessing and referring clients, and training supervisors to use a job performance focus) were performed clearly more often than any of the noncore tasks. Four of the least frequently used core tasks (publicizing EAP policies to employees, interfacing with insurance providers, developing an EAP policy, and informing departments on use of the EAP) are not performed more often than the three most frequently used noncore tasks (providing long-term counseling, training supervisors on clinical issues, and developing wellness programs). They conclude that the core tasks are generally perceived as more important than the noncore tasks they identify but that EAP professionals engage in some noncore activities at least as often as they engage in some core tasks. According to the authors, this is due to the role of outside groups such as management and labor in defining the activities of EAP professionals and the influence of educational and professional training on their activities.

Fiedler, N., Bowden, J., Kelly-McNeil, K., Steinberg, M., & Gochfeld, M. (1991). Employee assistance program compliance: Impact of contrasting insurance coverage. Journal of Occupational Medicine, 33, 862-867.

According to the authors, some research has been conducted to determine the effect of EAPs on absenteeism and disciplinary action, but little information is available regarding compliance with clinical recommendations (i.e., initiating and remaining in prescribed treatment). This article reports on the results of a study to evaluate the effect of two different rates of insurance coverage for outpatient mental health services offered by two comparable blue-collar work organizations.

The organizations were similar in occupation (operating toll roads), nature of work, pay scales, and level of job skill. Also, subjects in the study were similar in demographic profile, employment, seniority, and union affiliation. Both companies were self-insured; however, the companies differed greatly in the level of insurance coverage offered. Company A paid for 80% of the fees per session up to a maximum of $2,000 per calendar year, after a $100 annual deductible. Company B’s plan provided 50% copayment on a maximum fee of $40 per session (or no more than $20 per visit) with a maximum of 50 visits per year ($1,000 per year), with a $75 annual deductible. The level of coverage offered constituted the single independent variable for the research. Forty-two subjects from Company A and 61 employees from Company B were included in the study. The number of treatment contacts with providers to whom subjects were referred constituted the dependent variable for the study. Data were collected from treatment providers by use of a questionnaire to document the number of treatment contacts.

The researchers found that employees from the organization with a higher rate of payment (Company A) were significantly more likely to initiate treatment and to remain in treatment longer, whereas those from the organization with the lower rate of payment (Company B) were more likely not to comply with the treatment recommended by the EAP. This outcome was not accounted for by demographic differences between the groups or by differences in diagnostic categories or treatment approaches. If the ultimate mission of the EAP is to improve the performance of troubled workers, then levels of treatment improvement are critical to their success. To the degree that remaining in treatment is a surrogate for treatment improvement, this study supports the desirability of providing adequate benefits to cover recommended treatment. As EAPs serve not only as gatekeepers (assessment, referral activities) but also as care management groups (aftercare, follow-up activities) to contain costs, their effectiveness is dependent on their skill to prepare clients for treatment and the availability of resources to support care.

Foote, A., & Erfurt, J. (1991). Effects of EAP follow-up on prevention of relapse among substance abuse clients. Journal of Studies on Alcohol, 52, 241-248.

In this article, the authors report on the results of follow-up services provided to clients entering the EAP of a large manufacturing plant in 1985 who were assessed as having an alcohol or drug abuse problem (N = 325). Clients were randomly assigned into an experimental "special follow-up" group and a control "regular care" group. The regular care group received follow-up only as needed, following the usual practice of the EAP. A follow-up counselor was hired to make routine contacts with the special follow-up group. Follow-up continued through the end of 1986. Data collected on the study subjects included EAP participation data, absenteeism, number of hospitalizations, health care claims, and disability claims paid. The major study hypothesis was that EAP clients randomly allocated to a special follow-up would show better results than regular care clients (i.e., would have fewer relapses, better job attendance, and lower health benefit utilization during the follow-up year).

The special care follow-up group was to be contacted weekly by the counselor for the first month after treatment, monthly for the next 5 months, and then bimonthly. However, in the case of relapse or the threat of relapse, the frequency of follow-up was to revert to weekly. Each contact was intended to demonstrate concern and support, reinforce the importance of controlling the problem for health and job security reasons, and offer help if the employee was feeling unable to cope. The number of follow-up contacts was expected to be 13 to 20 for members of this group but averaged only about 7. The follow-up intervention was incompletely implemented due to a variety of organizational problems and clients’ decisions to drop out of follow-up care.

Differences between the two groups on the six outcome measures were not statistically significant, although clients in the special care follow-up group did show better results than clients in the regular care group on the three measures related to substance abuse (substance abuse disability costs, substance abuse treatment costs, substance abuse hospitalizations). Differences on these three measures were marginally significant in regression analysis after controlling for the effects of number of follow-up visits, age, race, and chronicity. The authors suggest that similar studies should be attempted in other work sites, with more rigorous implementation of the intervention protocol over longer periods of time.

French, M., Zarkin, G., & Bray, J. A. (1995). Methodology for evaluating the costs and benefits of employee assistance programs. Journal of Drug Issues, 25, 451-470.

The authors depict EAPs as a relatively new fringe benefit for workers. Despite the growth in prevalence of these programs, few studies have estimated their costs and benefits independent from treatment costs and outcomes. The authors present a methodology for economic evaluation consisting of four components. First is a process description to understand the structure, operating environment, goals, cost elements, and key outcome variables of the EAP. Second is a cost analysis to comprehensively identify and estimate the full range of EAP costs taken from actual program and work site expenditure data (not from budget information). Third is an outcomes analysis to rigorously estimate the effectiveness of the EAP on employee performance and workplace productivity within specific time frames for well-defined client and organizational goals. Fourth is an economic evaluation to estimate cost-effectiveness ratios, dollar benefits, and net benefits of the EAP. The methodology is based on standard economic theory, but the evaluation strategy is presented in a nontechnical way so that it can be used by employers and other researchers to estimate the costs and benefits of EAPs.

Googins, B. (1991). Revisiting the role of the supervisor in employee assistance programs. National Institute on Drug Abuse, Drug abuse services research series, No. 1: Background papers on drug abuse financing and services research (pp. 289-304). Rockville, MD: U.S. Department of Health and Human Services.

Supervisors have been at the heart of the unique identification, confrontation, and intervention that make up EAPs. However, workplace strategies for intervening with drug and alcohol problems are entering new phases of development. As the EAP field evolves over the next decade, it has an excellent opportunity to revisit the efficacy of the supervisor role. Anecdotal accounts suggest the demise of supervisor training, constructive confrontation, and supervisor referrals. No adequate data are available to prove or disprove these claims; however, it is apparent that the supervisor’s role has diminished in many quarters. The EAP faces a conceptual challenge: How essential is the supervisor to the EAP, and to what extent can we conceptualize and operationalize an EAP without active supervisory participation? Will the traditional models of constructive confrontation hold up, or will supervisors become inconsequential and unnecessary to the overall EAP strategy?

The author asserts, based on review of several relevant studies, that the role of the supervisor today is considerably more complex than in earlier days of occupational alcoholism programming. Supervisors operate in a changing organizational context that includes managed care and drug-testing programs. These, and the movement toward increasing self-referrals, have diminished the traditional involvement of supervisors. Although the role of the supervisor has shifted, the author concludes that its importance has not diminished. If anything, it has become more important. The EAP requires close relations with supervisors to carry out its mission, not only to refer drug and alcohol abusers to treatment, but also to help programs become more fully integrated in the workplace. The supervisor’s broader range of services will reflect not only constructive confrontation, but also more preventive strategies.

Harris, M., & Fennell, M. (1988). Perceptions of an employee assistance program and employees’ willingness to participate. Journal of Applied Behavioral Science, 24, 423-438.

his article discusses the factors related to workers’ decisions concerning their willingness to use EAP services. The authors review several studies that relate worker attitudes, social and environmental issues, knowledge of and attitudes toward the program, and the type and magnitude of personal problems to the decision to seek help from an EAP. A random sample of 100 employees of a publicly held financial institution in a midwestern metropolitan area were surveyed to determine workers’ attitudes toward, perceptions of, and willingness to use various resources for help with alcohol dependence; their beliefs about the causes and stigma of alcoholism and reasons for drinking; and their levels of alcohol consumption. In addition, 50 of their supervisors were randomly selected and surveyed on these topics. The results were analyzed using multidimensional scaling techniques and indicate that men and women appear equally willing to use EAPs, although they differ somewhat in their perceptions of and attitudes toward them. Willingness to use the EAP for alcohol-related problems was associated with perceptions of trust, attention, and familiarity for both gender groups; but women were more likely influenced by their familiarity with the program, and men by perceptions of the program’s effectiveness and control.

The authors also found that willingness to obtain help from an EAP was greatly influenced by respondents not believing that alcohol is an effective way to reduce stress. Also, alcohol consumption was negatively associated with willingness to use an EAP among drinkers, although abstainers were also relatively unwilling to use EAPs.

Hartwell, T. D., Steele, P., French, M. T., Potter, F. J., Rodman, N. F., & Zarkin, G. A. (1996). Aiding troubled employees: The prevalence, cost, and characteristics of employee assistance programs in the United States. American Journal of Public Health, 86, 804-808.

This study reports on results of a national prevalence survey of work sites conducted in 1992-1993 concerning the prevalence, cost, and characteristics of EAPs. The study found that 32.9% of all work sites with more than 50 employees had such programs and that they served 55.3% of the national work force employed in these work sites. This is indicative of a substantial growth in the prevalence of programs, as compared to the results of the Bureau of Labor Statistics survey of 1988, using a similar methodology. EAPs were significantly more likely to be found in larger work sites and in the communication transportation/utilities industries. EAPs were significantly more likely to be found in work sites with high proportions of educated and unionized employees, and were less likely to be found in work sites with high proportions of minority employees. More than four out of five work sites with an EAP said that they contracted for that service (81.1%), although internal programs were more prevalent in larger work sites. Annual costs for external programs were slightly less ($18.09/employee) than for internal programs ($21.83/employee).

Hayghe, H. (1991). Survey of employer anti-drug programs. In S. Gust, J. Walsh, L. Thomas, & D. Crouch (Eds.), Drugs in the workplace: Research and evaluation data, Vol. II (Monograph 100, pp. 177-207). Rockville, MD: National Institute on Drug Abuse.

In 1988, the Bureau of Labor Statistics of the U.S. Department of Labor undertook a survey of employer antidrug programs. The objective of the survey was to produce estimates of the number of private nonagricultural establishments with drug-testing or employee assistance programs by size, industry type, and region. A sample of 7,500 establishments was selected from the Bureau’s Unemployment Insurance Address file, supplemented with the Federal Railroad Administration’s list of railroad establishments. The survey was conducted in two phases. First, a survey form was mailed to each sample establishment to determine if it had a drug-testing or employee assistance program. In the second phase, establishments engaged in drug testing and those with employee assistance programs were asked about the size and structure of their programs. Establishments not responding to questionnaires and those providing responses that needed further clarification were recontacted by computer-assisted telephone interviewing.

Survey results show that establishment size was the most important factor related to the incidence of drug-testing and employee assistance programs. For example, 43% of the establishments with over 1,000 employees had drug-testing programs, whereas about 2% of firms with fewer than 50 employees had these programs. Larger establishments were also more likely to have a formal, written policy regarding drug use. These differences could be attributed to the cost of programs and differences in hiring and management styles in small and large establishments. Differences in incidence by type of industry were much less, although establishments in mining, communications, public utilities, and transportation were most likely to have testing programs, partly due to regulatory requirements. Geographic region appears to have relatively little effect on the proportions of establishments with drug-testing or employee assistance programs.

The survey indicated marked differences in drug-testing practices. Some establishments only test applicants; others focus on particular occupational groups or those suspected of use; still others carry out random testing. Employers with testing programs placed a high priority on keeping potential drug problems out of the workplace. About 85% of the establishments with testing programs targeted job applicants, and 64% tested current employees. Only about 9% of all current employees tested positive for drugs, whereas 12% of applicants tested positive. These percentages are somewhat misleading, since only a small proportion of employers test, and much of the testing is performed on persons suspected of drug use.

Nearly 300,000 establishments were estimated to have EAPs. Roughly 90% were management sponsored, and most contracted for this service. The most common services offered were referrals to treatment (97%), counseling (77%), and follow-up (82%). Less frequent features included a hotline, drug education, and aid for family members.

According to the author, private industry efforts to reduce or eliminate drug problems in the workplace fall into categories of identification and assistance. Drug-testing and employee assistance programs are not widespread. Establishments with few employees are unlikely to have either type of program. Drug-testing programs are more likely to be aimed at applicants than current employees. Moreover, current employees tested are most likely to be those suspected of drug abuse. Even so, only about 1 in 10 of the applicants and employees tested positive for drug use. EAPs were mostly used to refer workers for treatment outside of the workplace.

Hayghe, H. (1991, April). Anti-drug programs in the workplace: Are they here to stay? Monthly Labor Review, pp. 26-29.

In 1988, the Bureau of Labor Statistics conducted the Survey of Employer Anti-Drug Programs to find out how many private nonfarm employers were taking steps to help prevent employee drug use and to find out what these steps were. Employers were asked whether they had any drug-testing programs, employee assistance programs, or formal, written policy statements regarding drug abuse by employees. The survey, however, did not generate information to indicate if the incidence of antidrug programs was changing over time. Therefore, in 1990, the Bureau conducted a follow-up survey of a sample of the employers who had participated in the 1988 survey. It indicates fairly rapid changes in the proportion of employers with antidrug policies and programs.

Less than 3% of small establishments had drug-testing programs in 1990, unchanged from 1988. Because these firms make up the majority (93%) of all U.S. work sites, there was virtually no change in the overall proportion of establishments with testing programs. However, the proportion of work sites with 250 or more employees conducting drug-testing programs rose from 32% in 1988 to 46% in 1990, and the proportion of work sites with 50 to 249 employees increased from 14% to 26%. About one-third of all work sites with testing programs in 1988 had discontinued them by 1990. Discontinuance was more likely in smaller work sites. About 16% of those that had dropped testing were considering reinstituting a drug-testing program. The author attributes changing positions on testing (starting and discontinuing programs) to changes in cost and effectiveness of programs, legal decisions, and legislation.

The proportion of establishments with EAPs increased from 7% to 12% between 1988 and 1990. Very large firms had the greatest increase. As with drug-testing programs, about one-third of employers had dropped their EAPs between 1988 and 1990. This was particularly the case with smaller employers.

By 1990, 15% of establishments had formal, written policy statements, up from 9% in 1988. As expected, larger firms were far more likely to have policy statements and more likely to have promulgated them since 1988.

In summary, evidence from the 1990 follow-up survey showed that during the 2-year period there was a strong tendency among larger firms to establish antidrug programs and policies. By contrast, small businesses, which were far more numerous, were much less likely to have begun such programs or policies. Moreover, substantial proportions of firms, especially small ones, had discarded their antidrug programs or policies between 1988 and 1990.

MacDonald, S., Albert, W., Maynard, M., & French, P. (1989). Survival analysis to explore the characteristics of employee assistance program (EAP) referrals that remain employed. International Journal of the Addictions, 24, 113-122.

This study examined characteristics of referrals to EAPs associated with subsequent termination of employment. Also, relationships between characteristics of the referrals and program characteristics were explored. The following types of independent variables were examined: client demographic characteristics, aspects of the client’s employment, types of problems, and the pathways of the EAP used by the client. Longitudinal data were collected at several time periods for 163 referrals to EAPs from five organizations. Survival analysis was conducted to determine which variables were associated with termination of employment. Females, older employees, members of married and cohabitating couples, and employees who worked for the organization for 5 or more years were most likely to remain employed. Factors not related to termination were job classification, type of problem, type of referral (either voluntary or mandatory), whether the client was referred inside or outside of the organization, and whether the client actually received treatment. One interesting finding was that people with alcohol problems were significantly more likely to be formal, rather than self, referrals to the EAP. The results suggest that different components of the EAP are suited to different people. Programs that have mechanisms for both voluntary and formal referrals, and that are broad brush rather than alcohol specific, will be useful to a wider sector of the work force.

Normand, J., Lempert, R., & O’Brien, C. (Eds). (1994). Employee assistance programs. In Under the influence? Drugs and the American work force (pp. 241-268). Washington, DC: National Academy Press.

This chapter examines three aspects of workplace responses to alcohol and other drug (AOD) use. First, it reviews some of the most popular activities and programs focused on the prevention of AOD use. Next, the discussion shifts to EAPs. The chapter concludes by examining treatment issues as they relate to program entry, treatment follow-up, and work site reentry.

Work sites have attempted to reduce the effects of AOD use on work settings through policy design and various health promotion activities. Common among these are attempts to alter individual risk factors that are associated with AOD use. Program activities are quite varied. Fielding and Piserchia analyzed data from the 1985 National Survey of Worksite Health Promotion Activities, a random telephone survey of work sites selected from the Dun and Bradstreet list of businesses that had work sites with more than 50 employees. Two-thirds of responding companies stated that they had one or more types of health promotion activities. The average number of activities was under three for those companies that offered any such activities. Worker participation in activities was not very high, and most activities were offered only once or intermittently. There is not strong substantiation in the research literature of the effectiveness of health-promotion activities in reducing employee AOD use.

Ideally, EAPs should make expert consultation and training available to supervisors and others; provide confidential and timely assessment services; provide referrals for treatment; establish links between the workplace and treatment providers; follow up with workers during and after treatment; and provide education and information on the prevention of AOD problems. It is also important that EAPs and managed care groups work closely to ensure that the level of care provided to employees will maximize their chances of recovery. Case finding is based on diminished job performance coupled with supervisor intervention (constructive confrontation) and on self-referral. Research suggests that EAPs have grown in popularity, especially since the 1970s. With few exceptions, implementation of EAPs in the private sector has been voluntary.

An average of 6% of employees use EAPs in work sites that have such a program. Research indicates that about 30% of caseloads involve AOD problems experienced by the worker, and AOD use by family members is implicated in many other EAP cases. Therefore, the caseload attributed to AOD use is considerable. AOD cases take more time from intake, referral, aftercare, and follow-up than do other EAP cases.

EAP effectiveness studies have been hampered by methodological flaws. However, Smith and Mahoney present insightful results of a study conducted at McDonnell Douglas Corporation. In this study, EAP clients receiving treatment for AOD and psychiatric problems were compared to workers who received treatment for similar problems but did not use the EAP. Subjects were tracked for 3 years after program entry or treatment. Results show that EAP clients had lower absenteeism, turnover rates, and medical claims than those who did not use the EAP. The authors suggest, however, that studies of the effectiveness of EAPs are limited because EAPs are not all the same in scope and intensity and should not be expected to produce the same results. More focused studies of specific aspects of EAPs are recommended.

The authors review the research findings related to several program activities. They find that supervisor training and awareness of the EAP has a positive effect on referrals to the program. Supervisory constructive confrontation and referral has been found to be an effective tool in addressing job performance problems associated with alcohol misuse and apparently more effective than self-referral or failure to refer clients to the EAP. Follow-up care by EAP staff significantly reduced subsequent AOD disability, hospitalizations, treatment costs, and health benefit claims for AOD use. Outcome studies, combining treatment and EAP follow-up effects, show significant improvements for program clients.

Overall, the weight of evidence from EAP evaluation studies suggests that the work performance and health benefit utilization levels of EAP clients return toward normal after intervention. However, the authors assert that it is misguided to ask whether the (generic) EAP is effective. They suggest, rather, that researchers should seek to understand how EAPs contribute to a range of different outcomes in a range of different settings.

The workplace has important linkages to treatment, with employees accessing directly through EAPs or indirectly through third-party payment. The workplace is important because of the constraints it may place on treatment and the role it may play in treatment entry, participation, employee maintenance, and relapse prevention. Workplace referral and the early intervention that can result from it are seen to benefit both the worker and the employer. Likewise, aftercare has been shown to have positive long-term effects. The authors assert that much of the thrust of EAPs has been on the detection of new cases, but given the propensity for relapse in AOD cases, they believe that greater emphasis should be placed on follow-up. Recovery should be viewed as a process rather than an event, with workplaces, EAPs, and treatment providers all playing important roles in aiding clients’ recoveries over the long term.

Reichman, W., & Beidel, B. (1989). Implementation of a state police EAP. Journal of Drug Issues, 19, 369-383.

In 1981, the New Jersey Division of State Police was the first law enforcement agency in the United States to be funded by the National Institute on Alcohol Abuse and Alcoholism for the development of an EAP. This paper discusses the design, implementation, and results of the process of program implementation and integration of the EAP within a police organization. Following from the work of Beyer and Trice, the authors hypothesized that the implementation of the program would follow the three-phase process of diffusion, receptivity, and use.

The state police were studied over a 3-year period. Questionnaires were sent to a stratified random sample of sworn members annually during the research period. The questionnaire contained items to measure the degree of diffusion, receptivity, and program usage. The results of the first survey indicate that the program was in the diffusion stage, with more than 69% of the troopers having heard of the EAP. Response to the receptivity items revealed that there was an awareness and sensitivity to the need for the program and its potential benefits. However, utilization of the program was relatively low at this time.

The results of the second survey showed that the diffusion stage was strengthened, with 78% of the respondents having heard of the EAP. However, receptivity and use had not increased. Results from the third survey were quite similar to those of the second survey.

Based on these results, the authors conclude that the program was largely in the diffusion stage and little into receptivity and utilization. Recommendations were made to enlarge and enhance stress management, alcoholism education, and marital relations training (not regular components of the EAP) to facilitate the program’s acceptance and overall integration into the Division of State Police.

Roman, P. (1991). The use of EAPs in dealing with drug abuse in the workplace. National Institute on Drug Abuse, Drug abuse services research series, No. 1: Background papers on drug abuse financing and services research (pp. 271-286). Rockville, MD: U.S. Department of Health and Human Services.

The author provides an overview of developing issues related to EAPs and results of a mailed questionnaire survey. The latter was an update of an earlier six-state survey of internal EAP practitioners. In 1988, 115 respondents provided information concerning client caseloads and the workplace environment in which they operated. It was found that drug abuse cases make up an estimated 10% of all EAP cases, with cocaine being the most prevalent substance of abuse, followed by marijuana. In contrast, alcohol cases make up about 20% of the reporting EAPs’ caseloads. The proportion of cases made up of nonalcohol drug cases had doubled from 1984-1985 to 1988. Further, the author reports that the drug abuse caseload is greater in companies that are stable in the size of their labor force; are economically stable or profitable; are unionized; have a drug screening policy and program; believe they have a major problem with drug abuse; refer drug cases to the EAP; and publicize the EAP, encouraging self-referrals for substance abuse problems. Improvement of supervisor training is positively associated with the proportion of drug abuse cases in the EAP caseload, and it is negatively associated with the number of EAP staff. In addition, the proportion of drug abuse caseload is positively associated with preferred provider organization arrangements and formal strategies for managed care of alcohol, drug, and mental health problems. More comprehensive EAPs, in terms of the scope of core technologies employed, are also more likely to have larger proportions of drug abuse cases. The proportion of substance abuse cases is positively associated with formal supervisor referrals, union referrals, and the time necessary to process these cases.

In summary, the results indicate that the more the EAP is geared toward involving supervisory management, the greater the extent of drug abuse emphasis. This finding confirms the general impression from research that it is difficult to obtain significant numbers of employee drug abuse referrals through EAP mechanisms that are not integrated into organizational management and that rely primarily on self-referral.

Roman, P., & Blum, T. (1993). Dealing with alcohol problems in the workplace. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 11, pp. 473-491). New York: Plenum Press.

The employee assistance program is the principal vehicle for workplace intervention directed at employees with alcohol problems. As broad-gauged programs, EAPs represent "mainstreaming" of alcohol problems into health care management. However, alcohol problems are defined broadly within EAPs, going beyond other definitions of alcohol dependence. The historical context is important for understanding EAPs and their dynamics. External environmental changes have affected EAPs considerably over the past decade. Particularly important has been the increased attention directed toward employee drug abuse. The approach adopted to handling drug users has been punitive and exclusionary, whereas the approach to those with work-related alcohol problems has been rehabilitation oriented. This is problematic, in that many who misuse alcohol also have histories of drug abuse. Also, growing attention has been given to the issue of managed care. EAPs have been a target for cost-containment efforts and have shown strong resistance to managed care efforts. However, managed care policies, such as using outpatient treatment options and establishing preferred provider organization relationships, seem to be growing among EAP providers. Further, the growing identification of dual diagnosis clients has affected EAP operation. Alcohol misuse could constitute self-medication for an underlying psychiatric disorder. It could also provide opportunities to circumvent cost-containment measures by drawing on multiple provisions for cost reimbursement.

Results of research about EAPs conducted over the past decade are reviewed. Growth in self-referrals and the importance of work peers and family members in the referral process are noted. EAP clients often suffer from high levels of depression. Constructive confrontation of workers by supervisors is likely to be an effective intervention strategy. Supervisory training has a significant positive impact on the ability and willingness of supervisors to use the EAP. EAPs are a valuable device for the identification, referral, and follow-up of alcoholic employees and can have a positive effect on the subsequent use of health benefits by employees and their families. EAPs can be agents for transforming the workplace culture into one that emphasizes sobriety and healthy behaviors. EAP work is coalescing into a distinctive occupational group.

The persistent issue of EAP efficacy is considered. The authors conclude that EAPs appear to serve many different purposes for different organizations. And, regardless of how one might assess the effectiveness of EAPs, there is yet to be offered any alternative for providing a systematic and constructive means for identifying and rehabilitating employed substance abusers.

The authors discuss factors that have limited EAP research. At present, there are no specific mechanisms for the funding of EAP-related research. Work site initiatives from NIDA and NIAAA have disappeared, in part due to a relatively low level of researcher response. Scientists engaged in alcohol research are more interested in epidemiology and primary prevention or in analyzing treatment outcomes. Because EAPs are a form of secondary prevention, relatively few scientists are actively engaged in this area of study. Also, most scholars are tied to specific disciplines, such as psychology or sociology. They could test key questions from their discipline in settings dealing with alcohol-impaired workers, but they have not "found" this research site or agreed to its value. A lack of common understanding of EAPs, a very heterogeneous group of programs and services, could also hamper research. Also, studies have been more evaluative in nature, with an audience of workplace administrators and operatives, rather than basic research oriented to the scientific community.

Sonnenstuhl, W. (1988). Contrasting employee assistance, health promotion, and quality of work life programs and their effects on alcohol abuse and dependence. Journal of Applied Behavioral Science, 24, 347-363.

Sonnenstuhl reports that EAPs have effectively used a dual strategy of constructive confrontation and counseling for dealing with problem drinkers at the work site. In many organizations, however, practitioners have begun to treat problem drinkers by altering this strategy and/or relying on health promotion programs (HPPs) and quality of work life (QWL) efforts. This article compares EAPs, HPPs, and QWL, discussing their theoretical underpinnings, methods, and demonstrated effectiveness in responding to alcohol abuse and dependence.

EAPs are based on the notion that supervisors can legitimately intervene with workers when their productivity is diminished. Sonnenstuhl cites studies indicating that diminished productivity could be an early warning of alcohol abuse and that appropriate humane intervention through EAPs can benefit both the work organization and the troubled worker.

HPPs have their roots in the public health ideology of prevention. Health promotion is a combination of voluntary educational, organizational, and environmental activities designed to support behavior conducive to the health of employees and their families. HPPs grew in prevalence during the 1970s as a result of management’s desire to control rising health care costs. In practice, programs seek to change employees’ unhealthy living habits, and little or no emphasis is placed on changing the organization or work environment. HPPs consider alcohol use to be a factor increasing one’s risk of death. Practitioners propose to control negative consequences by rehabilitating alcoholics and educating social drinkers. Little methodologically sound research indicates that HPPs are effective interventions with work-related alcohol misuse.

QWL is an offshoot of the organizational development movement and is based on the human relations ideology. According to this approach, when employees perceive that they influence work standards, their job satisfaction and performance increase proportionately. Although QWL theory does not explicitly address alcohol abuse and dependence, advocates generally believe that improvements in working conditions, job satisfaction, and workers’ self-esteem will ultimately reduce alcohol problems. Much epidemiological research has investigated the relationship between working conditions and alcohol abuse and dependence. Overall, findings suggest that a significant relationship may exist between working conditions and drinking behavior. However, there is little direct evidence that QWL efforts to improve the work environment have resulted in reductions of drinking problems.

Sonnenstuhl asserts that EAPs, HPPs, and QWL are workplace social movements competing for control of limited resources intended to deal with employee welfare. He suggests that each approach can contribute to the overall well-being of workers and their families and encourages cooperation among EAP, HPP, and QWL practitioners in addressing workplace factors related to drinking problems.

Sonnenstuhl, W. (1992). The job-treatment balance in employee assistance programs. Alcohol Health and Research World, 16 (2), 129-133.

In this article, Sonnenstuhl discusses the recent shift away from supervisor involvement and toward client treatment within EAPs. Historically, programs were based on a balance between constructive confrontation of poorly performing workers by their supervisors and the assessment and referral monitoring interventions provided for by EAP practitioners. From this perspective, the dynamics of the workplace and the treatment setting combine to motivate employees to comply with treatment recommendations. More recently, social and organizational forces have tipped the balance toward the dynamic of treatment and away from the dynamic of the workplace.

EAPs spend more time providing services to employees who come to the program voluntarily and less time ensuring that supervisors have the knowledge, resources, and support to perform constructive confrontations. The shift toward treatment has occurred because many businesses do not support the constructive confrontation strategy, since they think that supervisors will not use it and because it violates their notions of human relations. Also, some EAP workers trained in mental health treatment do not support what they believe to be a coercive strategy, and union officials are fearful that constructive confrontation could be used in a discriminatory and job-threatening way. Another force tipping the balance toward treatment is the influx of women into the labor force who appear to be more willing than men to seek professional help voluntarily for their personal problems. Further, EAP practitioners have been mobilized by management to focus on treatment cost containment rather than mechanisms for recruiting expensive and difficult treatment cases. Finally, the advent of workplace drug testing in the 1980s has deemphasized the role of the supervisor in identification and progressive discipline.

Although EAPs have been well accepted in American workplaces, few studies have rigorously evaluated them. Most research assumes that a balance between performance assessment and treatment exists and focuses more on program outcomes. Researchers do not investigate work processes that motivated employees to change their behaviors or actions of assistance workers to help employees change their behaviors. Unless the process of intervention is understood, program outcome results cannot be adequately interpreted.

Sonnenstuhl, W., Staudenmeier, W., & Trice, H. (1988). Ideology and referral categories in employee assistance program research. Journal of Applied Behavioral Science, 24, 383-396.

According to the authors, practitioners tend to employ cultural referral categories when classifying what has motivated clients to enter EAPs. When social scientists use these categories in quantitative research designs, interpreting the results becomes problematic. These categories are rooted in ideology and are used in ways that often conceal the diverse factors leading troubled employees to seek help. In particular, application of the term self-referral has grown dramatically, whereas application of the term supervisory referral has declined, which may reflect practitioners' underlying beliefs about how employees ought to use EAPs.

This article discusses the origins of these terms as associated with EAPs and current research on their use. It relates supervisory referral to the influence of Alcoholics Anonymous and the growth of the concept of constructive confrontation based on job performance as a strategy for workplace intervention. Peer referral is related to union reactions to the job performance model. Self-referral is grounded in counselors' reactions to issues affecting job performance. The rapid growth of the use of this term is consistent with the ideology of counselors who have entered the EAP field in growing numbers, indicating that they are allies of the worker (rather than the employer). Self-referral also indicates employee acceptance of the program.

The authors review a series of studies that show how cultural definitions of referral categories create methodological difficulties in quantitative analyses, making interpretation of the findings difficult. The authors review the medical and psychiatric literature on seeking help and call for construction of a grounded theory based on qualitative research. According to the general help-seeking literature, individuals with personal problems follow a natural progression through stages in which they seek and receive advice. In some cases, medical specialists and/or criminal justice agencies may intercede. Decisions to seek treatment are also affected by perceptions of mental health treatment, costs, and effectiveness. Within this context, social science researchers should reject cultural labels and conduct basic research concerning how workers define a problem that is best served by an EAP rather than some other community provider; under what conditions and from whom workers solicit advice about their problems; under what conditions and from whom workers receive unsolicited advice; how the process of seeking help varies according to the type of personal problem; and how this process varies according to the type of EAP. The authors recommend that EAPs develop more accurate classifications for labeling cases.

Steele, P. (1988). Employee assistance programs in context: An application of the constructive broker role. Journal of Applied Behavioral Science, 24, 365-382.

The author describes how practitioners in EAPs can adopt the role of constructive broker to achieve the goal of providing humane treatment to troubled workers. A constructive broker is one who facilitates joint action, primarily on matters important to the broker, among groups with varying interests, values, and goals. The context in which EAPs operate is discussed in terms of the labor process model, which holds that inherent ideological conflicts between management and labor make the workplace a contentious environment. In this environment, the EAP practitioner can serve as a constructive broker by advancing the goal of humane treatment for workers with alcohol and other drug problems through mobilizing the resources of management, labor, treatment, insurance, and managed care groups. The author presents strategies constructive brokers employ for enacting the role, including network mobilization, the use of functional marginality, selective adaptation, and identity management. Steele relates implementation of the constructive broker role to issues of cost containment, the role of programs in the workplace, and the professionalization of practitioners, all of which affect EAPs today. Effective constructive brokers must constantly remain aware of the role they play, their status relative to others in the network, and their original goals. Steele concludes that if employee assistance practitioners do not adopt the constructive broker role, their EAPs will likely become absorbed into other organizational units, which would make them less capable of fulfilling their humanitarian ideals.

Steele, P. (1989). A history of job-based alcoholism programs: 1955-1972. Journal of Drug Issues, 19, 511-532.

This article describes changes in the design of job-based alcoholism programs between 1955 and 1972 and discusses the influences of professional organizations, program practitioners, research, and government on programs. The author discusses the contributions of four professional organizations—the American Medical Association, the Yale (later Rutgers) Center for Alcohol Studies, the National Council on Alcoholism, and organized labor—to the evolution of programmatic designs during this period. He also describes the emergence of systematic research, particularly that of Harrison Trice at Cornell University. The development of state and federal initiatives concerning workplace programs is described in detail, culminating in the establishment of the Occupational Programs Branch of the National Institute on Alcohol Abuse and Alcoholism in 1971. Finally, he delineates the emergence of workplace alcohol program practitioners as a recognizable occupational group, with its own professional association, the Association of Labor-Management Administrators and Consultants on Alcoholism (now the Employee Assistance Professionals Association). A social movement perspective, emphasizing the natural history of the maturation of movements, is adopted to analyze general program development. This period is characterized as one of coalescence, reformulation, and regularization that was necessary before the explosive growth of programs in the following years could occur.

Steele, P., & Trice, H. (1995). A history of job-based alcoholism programs: 1972-1980. Journal of Drug Issues, 25, 397-422.

Steele and Trice extend their description of the development of Occupational Alcoholism Programs from their two earlier articles (by Trice and Schonbrunn [1981], discussing the period of 1900-1955, and by Steele [1981], discussing the period of 1955-1972, both in the same journal). They employ a longitudinal model of the social movements perspective to explain developments during this time period. The influence of four successive and interactive movement organizations— Alcoholics Anonymous, the National Council on Alcoholism, the National Institute on Alcohol Abuse and Alcoholism, and the Association of Labor-Management Administrators and Consultants on Alcoholism (ALMACA; now known as the Employee Assistance Professionals Association, or EAPA)—on the development of programs and the emergence of practitioners as an occupational group is discussed. The authors conclude that job-based programs experienced rapid growth, acceptance, and institutionalization during this period. At the same time, programs changed their goal from that of identifying and referring workers troubled with alcohol-related problems to providing counseling and referral services to workers with a broad range of personal problems. Also, practitioners changed from a populist focus to a more professional and entrepreneurial orientation and emerged as a recognizable occupational group. The authors note that employee assistance was separated from the workplace with the advent of external contractual firms that promoted program implementation from an entrepreneurial perspective. Practitioners formed a professional association (ALMACA) and formed new networks with insurance and treatment industries. Further, practitioners shifted from strategies that emphasized constructive confrontation and supervisor referral (grounded in the concept of workplace control of productivity) to strategies that focused on self-referral and family services (more consistent with the model of worker benefits, social services, and public behavioral health). The authors conclude that the goals and strategies of modern antialcoholism groups and advocates, which motivated the development of the job-based alcohol program movement, have been largely displaced by those who promoted programs during this period.

Tompkins, C. (1991). Drug abuse among workers and EAP programs. National Institute on Drug Abuse, Drug abuse services research series, No. 1: Background papers on drug abuse financing and services research (pp. 82-105). Rockville, MD: U.S. Department of Health and Human Services.

This article is divided into three sections. The first describes drug use in the employed population and associated impairments of job performance, EAP components and activities, employers’ motivations for developing EAPs, and distinctions between EAPs and managed care. The second presents a framework for measuring and evaluating the performance of EAPs. The last section presents empirical findings and discussion related to EAP effectiveness.

Research using the National Household Survey on Drug Abuse indicates high prevalence of illicit drug use among employed workers, resulting in great costs for industry. According to Tompkins, employee assistance program is a universal term for a set of company policies and procedures for identifying, or responding to, personal or emotional problems of employees that interfere, directly or indirectly, with job performance. EAPs provide direct services to employees, prevention and education, training and consultation for supervisors, and administrative support functions. They are very diverse, depending on several dimensions including their organizational locus, referral processes, use of outside providers, staffing patterns, financial arrangements, and range of problems addressed. The conceptual and programmatic roots of EAPs are in occupational alcoholism programs. Motivations for employers to establish programs include a perceived need in the work force that merits intervention (in the case of drug abuse, this could be related to high rates of accidents, criminality, absenteeism, and/or low job productivity or morale); the belief that EAPs are cost-effective and/or humane responses to personal problems of workers and their families; the position that EAPs are an effective protection against legal repercussions from workers sanctioned or dismissed for drug abuse; the suggestion that EAPs are needed to be in compliance with legislation and regulations; and the belief that EAPs must be the state of the art in human resource management, since so many other employers have them. EAPs are in apparent contradiction to the principles of managed care. That is, EAPs assume that both the employee and the organization benefit from improved access to quality care, whereas managed care principles assume that organizations benefit mostly by restricting (through screening and precertification procedures) access to care and thus saving health costs. The author suggests that EAPs could become important in the process of controlling costs by negotiating with providers and monitoring client outcomes.

From a public policy perspective, employers must consider whether they favor a punitive or supportive response to drug abuse among workers. To the degree that the latter perspective is supported by society and EAPs are effective, these programs are pervasive mechanisms in the public interest. Therefore, public policy debate may consider means to encourage or require employers to implement EAPs. This discussion would be informed by research results indicating which types of EAPs are most efficient and effective. Further, linkages to managed care, consolidation of the EAP industry, and drug testing in the workplace could affect the mission and/or operation of programs in the foreseeable future. Monitoring the evolution of EAPs and exerting influence where appropriate to reinforce their mission of getting drug users into treatment would be useful policy objectives.

Tompkins indicates that few methodologically rigorous EAP evaluation studies have been completed. He recommends that they measure program process, effort, performance (effectiveness), efficiency (cost benefit), and penetration (impact). Tompkins concludes by noting the need for rigorous outcome studies using longitudinal, cross-sectional, tracer, and case study approaches.

Steele, P. (1989). A history of job-based alcoholism programs: 1955-1972. Journal of Drug Issues, 19, 511-532.

This article describes changes in the design of job-based alcoholism programs between 1955 and 1972 and discusses the influences of professional organizations, program practitioners, research, and government on programs. The author discusses the contributions of four professional organizations—the American Medical Association, the Yale (later Rutgers) Center for Alcohol Studies, the National Council on Alcoholism, and organized labor—to the evolution of programmatic designs during this period. He also describes the emergence of systematic research, particularly that of Harrison Trice at Cornell University. The development of state and federal initiatives concerning workplace programs is described in detail, culminating in the establishment of the Occupational Programs Branch of the National Institute on Alcohol Abuse and Alcoholism in 1971. Finally, he delineates the emergence of workplace alcohol program practitioners as a recognizable occupational group, with its own professional association, the Association of Labor-Management Administrators and Consultants on Alcoholism (now the Employee Assistance Professionals Association). A social movement perspective, emphasizing the natural history of the maturation of movements, is adopted to analyze general program development. This period is characterized as one of coalescence, reformulation, and regularization that was necessary before the explosive growth of programs in the following years could occur.

PREVENTION PROGRAMS

Fielding, J., & Piserchia, P. (1989). Frequency of worksite health promotion activities. American Journal of Public Health, 79, 16-20.

This article reports on the results of the National Survey of Worksite Health Promotion Activities. It surveyed a random sample of all private-sector work sites with 50 or more employees, stratified by number of employees, geographic location, and type of industry. A response rate of 83.1% (N = 1,358) was achieved. Of responding work sites, 65.5% had one or more areas of health promotion activity, with slightly more than 50% of activities initiated within the previous 5 years. Overall prevalence by type of activity included smoking cessation (35.6%); health risk assessment (29.5%); back problem prevention and care (28.5%); stress management (26.6%); exercise/fitness (22.1%); off-the-job accident prevention (19.8%); nutrition education (16.8%); blood pressure control and treatment (16.5%); and weight control (14.7%). The mean number of activities across all work sites was 2.1, and for work sites with activities, it was 3.2. Activity frequency increased with work site size, was highest in the western region (2.34) and lowest in the Northeast (1.96), and was more prevalent in service and manufacturing industries. The majority of work sites paid the entire cost of these activities. The authors conclude that although the contribution of work site health promotion activities to achieving national health promotion objectives cannot be gauged from this study, all of the types of activities studied support specific awareness and risk-reduction objectives, and their availability to millions of employees suggests that the workplace be considered an important delivery site in any national risk education effort.

Heirich, M., Erfurt, J., & Foote, A. (1992). The core technology of work-site wellness. Journal of Occupational Medicine, 34, 627-637.

Work site wellness programming has evolved through four stages of development. These have been the introduction of health relevant policies to work sites for reasons unrelated to health; the deliberate introduction of health-related programs; the emergence of multiple-risk programs; and the development of broader programs focusing on disease care, prevention, and health improvement. This article proposes a core technology of work site wellness programs, based on research assessing varying program models between 1985 and 1988. The core technology proposed by the authors is composed of 10 dimensions that organize and systematize the range of activities undertaken by such programs. These 10 dimensions address the following tasks: (a) establishing program policy; (b) assessing the health status of the work force; (c) linking the work site with service providers; (d) linking individual employees with services appropriate to their needs; (e) providing options for behavior change strategies and interventions; (f) engaging employees in these various interventions; (g) organizing work site-wide activities to support health improvement; (h) reviewing and altering organizational policies to make the work environment more supportive of health; (i) routinely evaluating program process and changes in health risks; and (j) periodically assessing longer-term program results. Two future dimensions (developing comprehensive work site wellness centers and involving family members) are described that require further evidence of impact. Arguments and evidence in support of each dimension are provided, including discussion on how activities within each dimension work together to produce maximum effectiveness and how various dimensions relate to each other to make an effective overall program.