Considering counselling

A recent court ruling has highlighted the part workplace counselling can play in stress management. Chris Dyer reports on the role and effectiveness of these services.

Most people will suffer stress at some time during their working life. In some cases it will seriously impair the quality of work life and reduce personal and job effectiveness. It can originate from the job itself and from the context and arrangement of work, but equally it can originate from outside factors such as personal or family life.

It is widely recognised that stress is a major contributor to sickness absence, lack of mental wellbeing, alcoholism and other problems in the workplace. The HSE estimates that around a quarter of work-related illness is attributable to stress, with more than five million days lost each year. Stress-related ill health has received particular attention since employees have been successful in gaining compensation from their employers for psychological illness alleged to have been brought on by the employers' negligence.

The Sutherland judgment

In a recent Court of Appeal judgment, Sutherland v Hatton , the judges issued comprehensive guidelines on how cases of this type should be decided. In some cases the law has followed a middle way, treating recognised psychiatric illness as no different in principle from a physical injury or illness, while in others it has imposed additional "control mechanisms" so that liability does not extend too far. In the Sutherland case the court stressed several important differences between physical and psychiatric disorders.

  • The most significant relates to who knows what. The employer is, or should be, aware of what is going on in its workplace. It is much less aware of what is going on in its employees' minds or in their lives outside work. Many other people - family, friends and colleagues - are likely to know far more about this than the employer. Indeed, employees may wish to minimise or conceal the true state of affairs from their employer: no one wants to be thought unable to cope.

  • The employer is, or should be, largely in control of the workplace, equipment and physical conditions that work is done in. It is much less in control of the way that its employees, especially professionals or those who are expected to prioritise their own tasks, choose to do their work and balance the demands of their work and life outside the workplace.

  • The employer can be expected to take responsibility for keeping the physical risks presented by the workplace to a minimum. But responsibility for causing and for doing something about its psychological risks may be shared between many people - family, friends and the employees themselves. An individual who recognises that they are experiencing levels of stress that may be harmful has to make some decisions about how to respond to this. The employer's room for manoeuvre may in some cases be limited. At the extreme, its only option may be to dismiss the employee who cannot cope with the job.

    The Court observed that some people thrive on pressure, and are so confident of their abilities to cope that they rarely, if ever, experience stress, even in jobs that many would find extremely stressful. Others experience harmful levels of stress in jobs that many would not regard as stressful at all. It recognised the argument that stress is so prevalent in some employment, such as teaching, and employees so reluctant to disclose it, that all employers should have in place systems to detect stress and prevent its developing into actual harm. But the Court said this raised difficult issues of policy and practice that were unsuitable for resolution in individual cases before the courts.

    Employers should offer confidential help

    The Court concluded that more knowledge of stress issues might, in the future, justify employers being required to take particular steps to protect their employees from stress-related harm, and that if this were the case, it would be best done through regulations imposing specific statutory duties. In the meantime, the ordinary law of negligence governs the matter.

    In the light of this, the Court said that the key to the matter was to offer confidential help:

  • employees can then be encouraged to recognise the signs of stress-related ill health and seek help without fearing its effects on their job or prospects;

  • the employer need not make intrusive enquiries or over-react to problems it does detect;

  • responsibility for accessing the service can be left with the people who are best equipped to know what the problems are - the employee, their family and friends; and

  • ". . . if reasonable help is offered, either directly or through referral to other services, then all that reasonably could be done has been done . . . an employer who does have a system along those lines is unlikely to be found in breach of its duty of care towards its employees . . . except where it has been placing totally unreasonable demands upon an individual in circumstances where the risk of harm was clear."

    Three levels of intervention

    Research to date appears to suggest that the most effective way of tackling stress is to eliminate it at source, although most organisations that introduce strategies do so at the secondary or tertiary levels (see box 1). Most workplace intervention strategies emphasise improving the "adaptability" of the individual to the environment; there is much less organisational concern with adapting the environment to fit the individual. This approach would seem to be condoned by the Court of Appeal's guidance.

    One of the main interventions at an individual level to assist in the recovery and rehabilitation of stressed employees is workplace psychological counselling. This provides access to confidential professional counselling services for employees who are experiencing problems, either in the workplace or in their private lives, with the aim of helping the individual to work towards living in a way he or she experiences as more satisfying and resourceful. Counselling denotes a professional relationship between a trained counsellor and an individual, although counselling can include work with pairs or groups of people. The objectives of the counselling will vary according to the clients' needs and may include developmental issues, addressing and resolving specific problems, making decisions, coping with crisis, developing personal insight and knowledge, working through feelings of inner conflict or improving relationships. Organisations may buy in counselling services or employ counsellors, perhaps as part of an occupational health service.

    Employee assistance programmes

    A development of workplace counselling is the multi-modular employee assistance programme (EAP), usually delivered through an expert external agency and funded by the employer. The UK Employee Assistance Professionals Association (EAPA)1 - essentially a trade body for EAP providers - defines an EAP as "a mechanism for making counselling and other forms of assistance available to a designated workforce on a systematic and uniform basis and to recognised standards". An EAP is a worksite-focused programme to assist in the identification and resolution of employee concerns that affect, or may affect, performance. Such employee concerns typically include, but are not limited to:

  • personal matters - health, relationship, family, financial, emotional, legal, anxiety, alcohol, drugs and other related issues; and

  • work matters - work demands, fairness at work, working relationships, harassment and bullying, personal and interpersonal skills, work/life balance and stress.

    The potential strength of EAP/counselling services in industry, according to the EAPA, is that "they function to minimise the damaging consequences of personal distress to the mutual benefit of the individual employee and employing organisation". Ideally, providing professional assistance to the employee - in the form of short-term, focused, confidential counselling or referral to a specialist resource - means early intervention and control over issues that may otherwise develop into a crisis. This could help to avoid unnecessarily damaging consequences, both for the individual and the organisation.

    Drawing distinctions between types of counselling services is difficult; even the obvious distinction of internal and external counselling services is blurred by the fact that an organisation's internal service may refer a client to an external provider for specialist help. Furthermore, almost all personnel specialists and managers are engaged in some kind of activity that could be termed "counselling". But counselling can be considered a continuum that ranges from advanced psychotherapy to line managers and supervisors who have no structured training, but who possess an intuitive conviction that their experience and natural talent will suffice. Nevertheless, the skills needed to be effective in professional counselling are usually developed through training in a socio-psychological discipline and the sensitivity required is normally developed through directed practice. The popular view seems to be to regard counselling as being for less serious problems than psychotherapy.

    UMIST research

    In 1998, the HSE published research it had commissioned from the University of Manchester Institute of Science and Technology (UMIST) into employee assistance and workplace counselling programmes in British organisations.2 UMIST surveyed EAP providers, EAP counsellors and organisations offering counselling services to their employees. The research covered 23 internal counselling services that were providing 618,000 employees with counselling, and 122 external counselling services that were providing counselling to 197,000 employees. Based on its research, UMIST estimated that about 1.3 million employees - 5%-6% of the working population in Britain - were covered by a counselling service. Research carried out for the EAPA in 2002 found that there are now 1,137 organisations that have EAPs in the UK, covering some 2.26 million employees (around 10% of the UK working employee population). Another 304 organisations, comprising 1.79 million employees, are covered by telephone counselling helplines only.

    The advantages of contracting out are:

  • confidentiality may be seen to be greater;

  • for small companies, it may be more cost effective (see box 2); and

  • external counsellors may have more expertise in specialised counselling situations.

    The main advantages of providing a service in-house are:

  • counsellors know the company culture; and

  • if problems are identified, it is easier for counsellors to influence managers, whether to help the employee or to modify his or her own behaviour or the company's practice.

    Overall, those organisations that had decided to provide a counselling service, whether provided internally, externally or as a combination of both, felt the important reasons for introducing a counselling service were:

  • to help employees adapt to change;

  • to respond to high stress levels within an organisation;

  • to support staff generally; and

  • to "appear" to be a caring organisation.

    Improved productivity, reduced absence or reduced unwanted labour turnover tended not to be reasons for providing a service.

    Internal services were usually introduced because organisations genuinely wanted to support staff and address organisational issues and problems. In-house services appeared to have a better appreciation of an organisation's policies, procedures and culture.

    EAPs are more often purchased for public relations reasons and to assure employees about confidentiality and independence. They also offer additional services and are usually available to an employee's family members (87% in the UMIST research), whereas internal services rarely extend to the family (28%).

    Internal provision was likely in organisations in which an occupational health or welfare department suggested a service might be helpful. Contracted-out provision was more likely where a human resources department suggested introducing a counselling service.

    Core activities

    The UMIST study found little consensus among providers as to what constitutes an EAP. Providers said that core activities were:

  • initial, ongoing advertising of the EAP (80%);

  • orientation sessions for managers and employees (80%);

  • provision of face-to-face counselling (90%); and

  • statistical and detailed feedback to the client organisation (70%).

    Generally, the providers did not see essential EAP ingredients as including legal and financial advice, 24-hour access, telephone counselling and crisis back-up. Some felt that training, such as stress management techniques, relaxation and assertiveness training, should be an integral part of an EAP. Others stated that legal and financial advice should always be available as part of an EAP, but suggested that this should be delivered directly to the client by a qualified legal consultant. There is thus scope for flexibility in the design of EAPs and counselling programmes, so that core activities may not necessarily be provided by the external counselling provider, but may be provided by the organisation in another way.

    The importance of feedback

    A majority of providers told UMIST that detailed feedback to the company was essential; it highlights policy issues and general areas of work organisation that should be of organisational concern, which the company can then attempt to change structurally, reducing the stress that the organisation imposes on the employee. This is an important point: although EAPs aim only to address stress at an individual level, there is also a need to address stress at an organisational level. But according to some EAP providers, doing this within the framework of an EAP risks compromising confidentiality.

    Feedback is an essential component of a responsive and constructive counselling service. The provider should report to a coordinator within the client organisation any current or emerging organisational trends that are apparent from analysis of the problems presented by individuals. UMIST suggests that providers should be proactive in suggesting steps that an organisation might take to minimise any adverse effects of organisational developments, thus moving closer to primary prevention.

    The UMIST researchers believe that services that combine the best of internal and external provision are likely to function best in this sense. An effective combination would seem to be an internal company counsellor who has the back-up of an external service, either for cases that the counsellor feels unable to deal with or, in some cases, for employees to contact directly if they wish to.

    But the best type of service, says the UMIST study, could be of a type not seen in the research. In this model, a company pays an external provider to supply it with its own dedicated company counsellor/s. This counsellor would regularly visit the company and get to know its culture, policies and procedures, although responsibility for the provision and supervision of professional counselling would be held by the external provider, ensuring confidentiality and quality. This would address the negative aspects of external provision, such as lack of integration in the company, and of internal provision, such as a lack of perceived confidentiality. And the counsellor would be in a position to give effective feedback to the organisation on issues that need addressing.

    THE NHS MODEL

    Research in the NHS3 has found that many NHS employees suffer high levels of psychological distress. The problem is significant and the associated costs, both human and financial, are high. This has resulted in an increasing number of NHS trusts arranging access to counselling services for their staff; a specific aim in the NHS human resources policy is that all staff should have access to a counselling service. Many of the counselling services have been "bought in" from external providers, although some trusts have used existing staff to provide the service in-house.

    In response to the increasing use of counselling services, the NHS has produced guidance on setting up or buying in services.4 Although written for NHS managers, it is equally applicable to other organisations and provides criteria against which the quality of a service can be judged.

    The guidance notes that terms in common use within the counselling field that can cause confusion include EAP, employee counselling programme (ECP), staff support, post-incident debriefing and staff counselling. The terminology used in individual workplaces, it says, is not important, provided managers and staff are aware what services are being provided and what they can expect. Any problems with terminology can be addressed through education and training.

    It can be argued, the guidance says, that an EAP that offers a variety of services could more appropriately be called a staff support service. But while it is possible to buy in the services of an EAP, the term "staff support" implies a much more integrated approach to looking after the wellbeing of staff. A bought-in EAP or counselling service is, by definition, separate from management and staff, and obtaining feedback may be difficult unless this is written into the contract when negotiating the service. A staff support service that is integrated into the management of the organisation, with supporting policies and procedures, will enhance evaluation and facilitate changes where policies are obviously failing to meet expectations.

    The NHS guidance echoes UMIST's recommendation that the ideal model is a staff support scheme, integrated into the management of the organisation and supported by bought-in services that cannot be provided in-house. This presupposes provision of a wider range of integrated services than the minimum acceptable service suggested by the guidance.

    Minimum service

    A quality counselling service, as described by the NHS guidance, will provide, as a minimum:

  • face-to-face contact with individuals, which is an essential feature of a counselling service. The short-term model of consultation, five to eight sessions, is likely to be the most appropriate; and

  • telephone contact (as opposed to telephone counselling), which allows individuals to refer themselves to the service. They can then choose whether to take the consultation further and book for face-to-face counselling. This also provides easy access for staff with difficult shifts.

    Telephone contact must not be seen as an alternative to face-to-face consultation, but as a means of accessing help. Some organisations will also need to provide access to counselling in response to traumatic incidents.

    As with all staff health, safety and welfare issues, the service should be integrated into the core management practices of the employer and close links should be encouraged with the disciplines of health and safety, occupational health, human resources and health promotion. The counselling services should be geared to the needs of the organisation and its employees and be staffed by competent and appropriately trained personnel. Arrangements should be made for employees to have access to, and advice from, external service providers where the full range of services is not available in-house. There should also be a written protocol covering the accessibility of the service.

    SETTING UP A SCHEME

    For a counselling service, whether bought in or provided in-house, to be effective it will need to perform several important activities, including:

  • providing effective promotion and publicity of the services, and how to use them;

  • confidential, appropriate and timely problem assessment;

  • short-term professional counselling and other assistance;

  • referral for appropriate diagnosis and longer-term treatment and/or assistance;

  • channels for feedback about the service, its role and how clients are using it; and

  • anonymised feedback to the employer on use, range of issues and any specific problem areas identified.

    Confidentiality

    Confidentiality is crucial to the working relationship. Counsellors should develop a policy with the HR department that is available throughout the organisation (see box 3). Policies should include explicit references to guidance from the British Association for Counselling and Psychotherapy (BACP).5

    Education

    An employer introducing a counselling service should provide an educational programme for all who work in the organisation to show:

  • that anyone can suffer psychological distress and that this should not be seen as a stigma;

  • that counselling is not only for those suffering psychological problems, but covers other subjects including people management, debt, training and breaking bad news;

  • that psychological problems and stress are not normally a cause for concern for other staff and those having dealings with the organisation; and

  • how the service operates and what it provides.

    Access and publicity

    Although most cases that a service sees will be self-referrals, others will follow a colleague's recommendation. The guidance says that recommendations must be made with care, as counselling will succeed only if people partake voluntarily. Those who are expected to recommend the service should be briefed on how best to refer. The guidance points out that hours of availability need to allow all staff reasonable access. Managers should liaise with other departments, such as occupational health, to ensure appropriate services, including out-of-hours, if only by telephone.

    Counselling service uptake is directly related to the quality and effective dissemination of its publicity. This may include presentations to staff groups at all levels, inductions, posters, leaflets and articles in in-house publications. Publicity needs to be continuous if the service is to maintain a high profile. Eventually, word of mouth is likely to be the most effective form of publicity, but in the early stages, more conventional mechanisms are vital.

    Qualifications and affiliations

    The guidance stresses that counsellors should hold an appropriate qualification in counselling. The generally recognised minimum professional qualifications are at diploma level and include a diploma/MSc in counselling psychology as recognised by the British Psychological Society. The BACP operates a counsellor accreditation scheme. Counsellors should have either BACP accreditation or training and supervised practice to the level required for BACP accreditation.

    The guidance also recommends that both in-house and external service providers should be affiliated to a recognised professional body, such as the BACP or the UK Council for Psychotherapy (UKCP). Affiliation provides a professional and ethical framework for the service through a code of practice and thereby a degree of safety for clients, the service and the wider organisation.

    Employing counsellors with the right qualifications and a good understanding of the organisation's culture will not in itself guarantee an effective counselling service. Successful services will have also taken account of the contextual issues below, which can have a determining influence on whether a new service prospers or fails.

    Location

    The perceptions of staff about the confidentiality of the service and the extent to which they can use it discreetly will be influenced by how and where it is located. The guidance suggests the location should easily accessible, but not obvious to passers by. This allows clients to use the service without feeling exposed to the gaze of others, and will reinforce the confidentiality of the service. Furthermore, clients are often worried that they may meet someone they know when using a counselling service. For this reason, whatever the location, the waiting area ought to be where passers by cannot see waiting clients.

    A counselling service should be integrated into an organisation's management but, at the same time, it must be perceived as being outside the routine processes of the organisation. It must develop a reputation for being independent and confidential and encourage the view that it is a safe place to bring problems.

    Organisational structure

    The commonest lines of reporting in existing services are through human resources departments. The boundaries of this relationship need to be clearly defined and carefully negotiated so that responsibility for issues of clinical practice and day-to-day service delivery lies with the service manager. Whoever the service reports to, the guidance recommends this person has a good understanding of workplace counselling and should act as a champion for it.

    Resources

    Many services fail because they are inadequately resourced from the outset. The administrative infrastructure needs to be right, with office amenities for in-house provision budgeted for including furniture, office equipment and funds to develop publicity materials. Counsellors who may be asked to play unexpected or appropriate specialist roles within the organisation, such as conciliation in a workplace dispute, may need additional training.

    Feedback

    It is important to develop clear channels for feedback on the service, its role and use. The content will vary according to the nature of the organisation, but should not identify individual users directly or by inference from the detail provided. Feedback would normally include a breakdown of usage by staff groups and issues. In a small organisation, where the numbers within specific staff groups may be small, the former may not be possible without jeopardising confidentiality.

    The guidance recommends that feedback should form the centrepiece of meetings with managers about the contribution of the service to the organisation, during which examples of staff concerns can be used to support the statistics. Such meetings also allow the employer to brief the service provider on developments likely to have an impact on the ways in which staff use the service.

    Organisational sponsors

    All services suffer setbacks at some stage, whether in terms of resources or acceptance by staff. The service needs sponsors within the organisation who have a good understanding of the service and its needs and who will act as champions at such times. The guidance suggests setting up an advisory group of stakeholders from important parts of the organisation that meets regularly to monitor and support the development of the service. Its composition will vary according to the organisation, but should include a member of the board who can act as sponsor. Ideally, the service should be able to count on the visible and active support of the chief executive, as this sends the right messages to staff about its importance.

    Trade union support

    The involvement of unions and staff organisations in the development of services, and on the advisory group, can, the guidance says, be an important factor in their success. If unions have confidence in the services provided, they are likely to portray them to their members in a positive light and may form a useful and appropriate referral source.

    External referral agencies

    Counsellors must be aware of agencies and individuals able to offer specialist or long-term counselling that falls outside the remit of their own service. If psychiatric back-up is not part of the service, then a source of external consultancy and referrals should be established. Where the counselling facility does not offer welfare, legal or careers guidance, it will be necessary to develop a local referral network.

    Buying in a service

    Employers must consider many factors when purchasing counselling services from an external provider. The level of service provision needs to be of an appropriate quality; the cost of purchasing counselling services may lead an employer to form partnerships with neighbouring organisations to ensure affordability and quality of service.

    Purchasers will also need to ensure that the provider can meet the criteria outlined above, and that it understands the nature of the organisation. Response times are important. Good practice dictates that an individual should be able to contact a counsellor within 48 hours of a request, but there should also be provision for distressed and at-risk individuals to make contact with minimum delay.

    The size and mix of the counselling team should be appropriate to the needs of staff. The team size should not be determined by the number of employees alone, but take into account factors such as the number of units and their locations and the types of work being carried out. Staff representatives should be consulted over setting up and reviewing the counselling service. Arrangements should also be made for continuing discussions, such as a user's committee.

    SERVICE EVALUATION

    Employers need to have a clear sense of what the service is trying to achieve, exemplified by well-developed aims and objectives. Audit and evaluation are important ways of measuring success and establishing quality control. Auditing the service against specific criteria, such as the length of wait for appointments, allows the development of benchmarks for service delivery and lays the foundation for subsequent audit and service development. User perspectives on service delivery also offer a valuable tool in developing services to meet an organisation's needs. Evaluating the effectiveness of clinical practice is equally important, allowing the service manager to address any issues of quality that may arise.

    Timescale

    It will generally take two years to establish the profile and credibility of the service with the workforce. During this period, uptake is likely to show a gradual increase, as more staff become familiar with the service and appreciate its professionalism. While the service may experience a respectable level of use during this period, any evaluation before three years has elapsed could prove premature. Milestones and objectives should be set for the service during this time, but no definitive judgment about its value and effectiveness should take place until it is well established within the organisation.

    Lines of responsibility

    It can be helpful to establish an advisory group that can meet regularly to monitor and support the service through its development. Although the composition of the group will vary between organisations, the inclusion of a board member who can act as a sponsor would be an advantage as it will help to stress the importance placed on the service by senior managers.

    Clinical supervision

    Regular clinical supervision of counselling is essential to the maintenance and development of professional practice. It is also a requirement of membership of the professional bodies for counselling and psychotherapy. A qualified and experienced counselling supervisor should supervise the counselling, in accordance with the requirements of the relevant professional body.

    Building on success

    The ideal model of counselling provision is one that forms part of an integrated staff support service. Such a service would typically offer careers guidance, advice on practical problems such as debt and housing and be able to undertake training and other group activities (see box 4). In so doing, the service is able to meet the widest range of employee and organisational needs. For example, someone facing redundancy might wish to see a counsellor about the stress of the situation, or an advice worker to explore the financial consequences.

    This type of service presupposes a multi-disciplinary approach employing individuals with specialist training and different professional backgrounds to offer a range of complementary services. A fundamental feature of the approach is the close links forged with those parts of the organisation concerned with staff welfare. In this way, a staff support service is able to develop a range of services more closely tailored to the needs of the organisation and can be responsive to its changing circumstances.

    QUANTITATIVE RESULTS

    As well as attempting a qualitative assessment of employee assistance and workplace counselling programmes, the UMIST researchers also tried to quantify the effects of the programmes.2 They used a questionnaire-based study of stress and wellbeing for individual employees and, at an organisational level, objective data such as sickness absence levels. The analysis was not straightforward and the researchers encountered difficulties with gaining access to providers and purchasing organisations, the refusal of some counsellors to administer the questionnaires, selecting a comparison group, confidentiality and extracting data, such as sickness absence, from company records.

    The research found that following counselling, individuals reported significantly improved general and work-related mental and physical wellbeing. But there were no reported changes for job satisfaction or any of the measures of the sources of pressure. This is to be expected, as counselling is aimed at helping individuals to cope better with their personal and work lives: the individuals maintain their view of the workplace because it is the same as it was before, so no changes result for job satisfaction or sources of pressure. But individuals are able to cope better and therefore should enjoy better mental - and probably physical - health.

    These beneficial effects arose mainly where internal counselling services were used, which may be due partly to their greater ability to deal with workplace issues. If an individual is counselled within the workplace context - and the counsellor is familiar with the organisation's culture, policies and procedures - it is likely that the counsellor would be more effective at helping the person to cope with their home and work life and thus improve their health.

    The researchers concluded that EAPs were less able to deal with organisational issues, mainly because the counsellor does not know enough about the organisation. Clients seeing an EAP counsellor are likely to be counselled as individuals but not within the context of the workplace (despite what EAPs can theoretically cover - see above): the whole of the person's life is not being addressed. If the counselling is restricted to an individual's problems and does not improve their ability to cope with work-related issues, then significant health effects are unlikely.

    Surprise finding

    Surprisingly, the researchers were unable to show that internal services had an impact on job satisfaction and sources of pressure. Such an effect would have been expected, given that internal services have the ability to feed organisational issues back to the company. The researchers offer three explanations:

  • the time span between the completion of the pre- and post-counselling assessment questionnaires was short - about 10 weeks. If an organisational problem was picked up and fed back to the organisation by a counsellor, it is unlikely that changes at an organisational level could be instituted before the end of counselling;

  • although internal counsellors have the opportunity to feed issues of employee concern back to the organisation, it is possible that they use their knowledge of the company to help the individual, but do not provide any feedback; or

  • the counsellor feeds issues back to the organisation, which chooses not to address them.

    When the researchers compared individuals who had received counselling with a control group, they found that individuals in the control group showed no changes in the scores for their physical or mental health, whereas the client group did. This suggests that the effects found for counselled employees are likely to be due to some extent to the counselling process.

    Research has suggested that counselling continues to have an effect for some time after it has stopped. This was not borne out by the UMIST research, which found no significant differences from post-counselling to follow-up, three to six months after counselling - indeed counselled individuals reported significantly more stress as coming from the "organisational structure and climate". The researchers suggest it could be that the longer-term impact of counselling was obscured by the clients' perception of more stress from the "organisational structure and climate". This result can be seen in a positive light, in that if employees were reporting more stress from their work a deterioration in their mental health would have been expected, whereas it remained unchanged. This effect could also be due to a company's failure to address organisational issues giving rise to stress. Following counselling, the failure of the organisation to take effective action is likely to prove even more frustrating and hence stressful.

    Sickness absence data

    The researchers found that, following counselling, fewer people were absent from work and those who were absent had fewer days off. (The same results had been found in an earlier evaluation of a counselling service in the Post Office - see box 5). There was no reduction for a matched control group. The study concludes that counselling affects the individuals' health (mental and physical wellbeing) and health behaviour (sickness absence), rather than organisational indicators (job satisfaction and sources of pressure). The use of counselling services, including EAPs, was found to affect the individual being counselled but not the whole employee population, in terms of mental and physical health, job satisfaction and coping with pressure. To have an organisational effect, an organisational-level intervention would also be needed. Simply introducing an EAP is unlikely to have an effect on organisational indicators, since an EAP does not have any organisational effect, although it does help individuals and reduce their sickness absence.

    The study concludes that individuals who have access to an EAP, but do not use it, do not benefit psychologically, or in terms of their job satisfaction or perceived sources of pressure, from knowing that it exists. Simply knowing that help is available will not reduce stress.

    Most workplace counselling programmes, including EAPs, concentrate on individuals with personal problems and attempt to reduce anxiety derived from financial, marital and family issues. This is obviously fundamental to helping an employee, both in terms of their personal happiness and work performance, but stress at work is caused by a complicated combination of personal and work-related issues.

    Effective counselling

    In order to be fully effective, counselling programmes at work must address both personal and workplace issues. UMIST's research found that many services do not do this. Using counselling programmes in the traditional way can shift responsibility for employee mental health from the company on to the individual employee. If a counselling programme operates purely at an individual level, then clearly the organisational sources of stress are not being tackled and the organisation can conveniently "forget" such problems because it provides a counselling service to help employees cope. The organisation is in effect distancing itself from the programme and hence the need to address problems of stress within the organisation.

    An EAP or workplace counselling service should, along with management, identify sources of stress within the organisation, and advise the organisation on appropriate means to help deal with these sources of pressure. EAPs and workplace counselling programmes should not be seen as a short-term, individual-based "sticking plaster" solution, but rather as a way of feeding back problems to the organisation (within the bounds of confidentiality) and empowering that organisation to help itself.

    The introduction of a counselling service may well benefit individuals psychologically, but there is unlikely to be an impact at an organisational level unless an intervention targeted at changing the organisation is also in place. British companies need to examine their reasons for buying a counselling service: if the aim is to support staff, a service will probably be useful in this respect. But if organisations are hoping positively to influence "bottom-line" indicators at the organisational level, they are likely to be disappointed.

    If a significant proportion of employees is reporting the early resolution of potentially serious problems and returning to work, it would be expected to show up in the bottom line. But it has been impossible to obtain quantitative proof, and so the decision to try a workplace counselling service is still more often a "leap of faith" than a measurable decision. Given that many employers are not merely concerned with showing a return on investment, this is likely to remain the case.


    Box 1: Stress reduction strategies

    Strategies for addressing stress fall into three categories:

  • primary prevention involves actions to reduce or eliminate the sources of stress and to promote a supportive and healthy work environment;

  • secondary prevention concerns the prompt detection and management of mental health problems, such as depression and anxiety, by increasing individual and collective awareness of stress and improving stress management skills; and

  • tertiary prevention deals with the rehabilitation and recovery processes of those individuals who have suffered or are suffering mental or physical ill health because of stress.


    • Box 2: The cost of counselling

    EAPs tend to be charged on a per capita basis based on several factors, including: the number of employees covered; the number of face-to-face sessions available per client; and other services provided, such as training or consultancy. The charges made for other workplace counselling services vary widely - some charge on a per capita basis and others use a "fee for service" payment structure where the fee is based on the number of hours' counselling that actually takes place.

    The average fee for an EAP in 1993/94 was about £25 per employee per year, with a range from £21 to £57. Anecdotal evidence suggests that counselling services can be as much as £60 per session, with an "initial assessment" fee of around £120.

    Whether a counselling service can be managed more cheaply internally or externally would seem to depend largely on the size of the company, with estimates of the point at which contracting out becomes more expensive than providing an internal service ranging from 3,000 to 10,000 employees.

    UMIST found that, in practice, organisations take the decision to provide a counselling service on grounds other than a straight cost-benefit analysis.


    Box 3: Principles of confidentiality

    These principles apply in all circumstances:

  • counsellors will not disclose any personal information gained in the course of their professional duties, unless given permission to do so by the client;

  • confidential information must be protected against improper disclosure when it is disposed of, stored, transmitted or received;

  • when clients give written consent to disclosure, the counsellor must ensure that they understand what will be disclosed, the reasons for disclosure and any likely consequences;

  • counsellors must respect clients' requests that information should not be disclosed to third parties, save in exceptional circumstances, eg where the health and safety of others would be at serious risk. This should be made clear to those who use the service via information leaflets and at the initial meeting;

  • only as much confidential information should be disclosed as is necessary for the purpose. Disclosure may be necessary in the public interest where a failure to do so may expose the individual, or others, to risk of serious harm. Counsellors should make sure that those to whom information is disclosed understand that it is given to them in confidence, which they must respect; and

  • counsellors must be prepared to explain and justify disclosing confidential information.

    Source: "The provision of counselling services for staff in the NHS", Department of Health.

    		•


    Box 4: An integrated service

    The following are common facilities important in integrated staff support services, whether provided internally or contracted out.

    Advice and information

    Many staff face problems in their working and domestic lives that are distressing and affect their ability to function at work. Some of these will prefer or need practical help rather than counselling. Providing an advice and information service can help such people, and can cover issues such as chronic debt, housing difficulties and legal problems. Advice workers can also bring a practical perspective to workplace concerns. The aim is to provide assistance and information that will enable individuals to resolve their problems.

    The expertise required to undertake advice work is varied, but regular "update" training in welfare rights and other legal issues is essential. Interviewing, negotiating and interpersonal skills are also important. As much of the work can involve liaison with external agencies, businesses and government departments, a sound understanding of local and national facilities is essential.

    Group work

    Staff support services may be involved in a wide range of group work within an organisation. Common examples include running support groups for staff engaged in stressful work; team building exercises, and running focus groups on issues of organisational concern, such as the effects on staff of workplace violence. Group work mostly involves counsellors offering direct facilitation, but, in some instances, they may provide initial support until the groups become self-running.

    Whatever the purpose of the group, managing group dynamics is skilled and difficult work. The expertise and resources needed to do it will, of course, depend on the work that is to be done, but counsellors should have attended relevant training and already have substantial experience of running groups. Separate supervision for group work is also appropriate.

    Careers guidance

    Careers advisers offer a forum in which individuals can explore the career options open to them and consider the implications of specific choices.

    Backed up by comprehensive information, careers advisers can identify educational and training needs and help staff to find courses or training that addresses identified skill gaps. Practical assistance with job searches, preparation of CVs and help with interview techniques, can be made available to those whose jobs are put at risk through organisational change.

    Training

    Staff support services usually offer a variety of training, made possible by the broad expertise that comes with a multi-disciplinary approach. Counsellors may also offer specialist training that could include courses and workshops on areas such as stress management, counselling skills for managers and developing effective workplace relationships. Advice workers who specialise in more practical concerns often run pre-retirement courses, workshops on financial planning and training aimed at particular staff groups.

    A good staff support service will play a pro-active role in developing training options that are attuned to the needs of the organisations they serve. They can also respond to ad hoc requests where a new training need has been identified. Consequently, the competency of staff improves and the organisation gets the benefit of expert training and its effect on the workforce. For the staff support service, training reaches many staff who might not otherwise use the service, while involvement in high-profile work of this kind establishes the staff support service ever more firmly as a familiar and valuable feature of the organisation.

    Organisational change

    The breadth of expertise in a staff support service makes possible the development of a package of support for staff that incorporates help with careers issues, advice on financial concerns and counselling for the emotional distress sometimes associated with change.

    Conciliation service

    Some staff support services offer conciliation, facilitated by counsellors, to help staff improve or rebuild damaged workplace relationships. The value lies in removing the conflict from the formal organisational arena where positions can harden and become entrenched. This allows the individuals to explore their problem in a confidential and non-threatening setting, and can produce resolutions to situations that are rapidly heading towards grievance and disciplinary proceedings and in which a mutually satisfactory outcome is highly unlikely. Conciliation is a difficult, but potentially highly effective procedure, provided the parties to the conflict approach it constructively. New approaches in staff support will constantly evolve in order to respond to novel organisational needs. Having a range of professional expertise allows staff support services to tailor their services to the needs of the individual organisations and leaves them well-placed to respond to changing needs.


    Box 5: The Post Office

    Research into the effectiveness of counselling services in the UK is sparse. One well-known study, carried out by the School of Management at UMIST and published in 1991, examined an internal counselling service set up in the UK Post Office.6

    In the early 1980s, the Post Office discovered that psychiatric and psychological disturbance ranked as the second-highest reason for medical retirement. As a solution, stress counsellors were employed in several regions on a three-year trial. The programme consisted of client-centred counselling, where postal employees attended individual sessions with trained clinical psychologists.

    In the three years of the research, the majority of counselling (46%) had been on mental health issues, with clients normally presenting symptoms of anxiety and/or depression. The second-largest group of clients (24%) were experiencing relationship problems, mostly marital. Other issues included addictions, bereavement, physical assault, physical illness or disability, social problems and panic attacks.

    Pre-and post-counselling data showed that: one in four individuals showed an improvement in absence events and days lost; six in 10 showed an improvement in anxiety and depression; and four in 10 an improvement in self-esteem.

    But there were no significant changes in job satisfaction or organisational commitment. The researchers suggest that as the counselling was aimed at increasing a person's ability to cope, it would be ambitious to expect it to act as a panacea for all organisational problems. To improve attitudes towards the organisation, it may be necessary to make changes at work by adopting primary stress reduction strategies. The researchers note that while work attitudes may not change after counselling, work behaviour is likely to change in terms of reduced absence, improved productivity and better relationships with colleagues.

    1www.eapa.org.uk.

    2"An assessment of employee assistance and workplace counselling programmes in British organisations", CRR 167/1998, www.hse.gov.uk/research/noframes/crr/1998/crr98167.htm.

    3"Improving the health of the NHS workforce: report of the partnership on the health of the NHS workforce", 1988, S Williams, S Michie and S Pattani, The Stationery Office, tel: 0870 600 5522, ISBN 1 902089 07 3, £10.

    4"The provision of counselling services for staff in the NHS", catalogue no.22156, Department of Health, PO Box 777, London SE1 6XH, free or www.doh.gov.uk/pdfs/nhscounsellingservices.pdf.

    5"Code of ethics and practice for counsellors", £1 members, £1.20 non-members, and "Ethical framework for good practice in counselling and psychotherapy", £6 members, £7 non-members, BACP, tel: 01788 578328. The code is also available, free, at: www.bac.co.uk/members_visitors/public_information/bacp_framework.htm.

    6"The impact of stress counselling at work", C Cooper and G Sadri, 1991, Managerial, occupational and organisational stress research, Cooper C (Ed), ISBN 1 84014 787 5, Ashgate, £99.50.