Pay attention to the science-backed workplace mental health frameworks that are taking shape outside the US, like those in Canada, Europe, and Australia.
In the US, the messaging of vendors and consultants tends to drown out science. Last year, for example, data from a meta-analysis — which included more than 120,000 research subjects — showed that job strain (the combination of high demands and low control at work) may lead to clinically diagnosed depression. This is consistent with a lot of other research that points us toward employer strategies for the primary prevention of mental health problems. But psychosocial risk and primary prevention are missing-in-action when we look at mental health resources made available by US employee wellness professional organizations and their vendors/consultant partners, .
Mental health crises — just like physical health crises — are mission critical, but this doesn’t mean we can’t prevent them before they happen and, what’s more, aspire to create workplace environments in which employee well-being flourishes.
Canada’s “Standard for Psychological Health and Safety in the Workplace” is a compelling example of a social strategy to promote mental health in all its stages — emphasizing primary prevention. Find out more about Canada’s Standard and other science-backed workplace mental health strategies on the Jozito mental health resources hub.
Summer’s here, and it’s time to unstrap the Fitbit and track some physical inactivity — the kind, for example, that takes place while reading. Pictured here is a pile of books that I’d recommend, or almost recommend, to wonky wellness professionals who have been at it for a while and are still searching.
You may think it weird that some of these books are old or even out-of-print. What good does an out-of-print book recommendation do you? Well, sometimes the story of a book is worth telling just as much as the story inside it.
Starting at the bottom of the pile…
Making Health Communication Programs Work.
Can you imagine there was a time — from 1989-2004, to be exact — when the US government gave this health communication book away for free? All you had to do was call and ask. This was the authoritative source on health communication — with more of a public health bent rather than employee wellness — affectionately known to health communicators as “The Pink Book.”
The good news is that you can get the final version of the book as a pdf. Who cares if it doesn’t include the last 13 years of developments? Who cares if the last entry in the glossary is a definition of “World Wide Web”? The book still covers an evidence-based approach to health communication theory and practice, with some behavioral change theory thrown in to boot. Get on it.
I’ve been studying the Hawthorne experiments for the last couple of years, and have assembled quite the collection of yellowed, musty, out-of-print books, this being one of the most important and, published in 1993, the most recent. At the heart of the matter is the field study of workers, supplemented with detailed interviews of 23,000 workers, under different conditions at Western Electric’s Hawthorne plant outside Chicago, in the 1920s and early 1930s. It stands as one of the most important studies of workers, management, and productivity ever.
While the Hawthorne researchers weren’t committed to worker wellbeing as we think of it, they did recognize wellbeing as relevant to productivity. And much of what we believe today about management styles, leadership, employee engagement, and teamwork was rooted in the Hawthorne research. Forget the fact that it started as a study of lighting, or that it had an entire category of bias named after it. Most experts today believe that if there is such a thing as the Hawthorne effect — in which research subjects change their behavior simply as a response to being observed — it didn’t occur at Hawthorne.
Let’s get real… You’re not going to read an old book about a 90-year-old study. So take 9 minutes to listen to this peppy BBC podcast on the topic. Regardless of the Freakonomics interviewee drawing an unfounded explanation of the Hawthorne findings, the podcast may start to give you a sense of how important the Hawthorne experiments are to our understanding of work, motivation, and even research design.
Yup, out-of-print — I don’t know why, as this is a seminal classic about the relationship between work and health, in which Robert Karasek, one of the most important worker health researchers of our time, lays out the case for the demand/control model of job strain.
Healthy Work may be too technical for a lot of people, but if you can get your hands on a copy, it’s great to keep around and skim through whenever you have a chance. Healthy Work changed how managers, health agencies, and labor organizations around the globe think about worker health.
Health Behavior and Health Education.
Get the 2015 version (5th edition), which is called Health Behavior: Theory, Research, and Practice. Health behaviors aren’t the foundation of employee wellbeing. (Exposures are.) But whether you agree with me or are convinced that, like people always say, “it all comes down to behavior,” isn’t it important to understand what makes health behavior tick?
This book was published in 2000 predominantly for clinicians and other wonks. It gets highly technical — so it’s not something you’ll want to read at the beach. But I keep it handy on my desk. It’s a collection of evidence documenting the relationship between work, psychosocial job stressors, and health, and suggesting a causal relationship — that is, bad jobs lead to poor health. The rigor of the studies contrasts with the vendor- and employer-fueled quasi-science to which wellness professionals are customarily subjected.
Amazon usually sells The Workplace and Cardiovascular Disease, used, for less than 10 bucks. If you want something cheaper and more current, you can try to access the article, “Globalization, Work, and Cardiovascular Disease,” published in 2016 in the International Journal of Health Services. Two of the article’s authors, distinguished researchers Peter Schnall and Paul Landsbergis, were among the editors of the book.
The only thing I find more painful than hearing our industry called the “ignorati” is noticing that we often do ignore criticism. Sure, we’ve all been paying the price for Al Lewis’s book ever since it was published, but we can be thankful that someone cast skepticism on the claims of the wellness industry. I don’t know if this is Al’s goal, but it is mine: To get better at supporting the wellbeing of the American workforce. In order to achieve this, we need to be able to assess our practices critically, and this book rallies us to do just that.
Former Washington Post reporter turned work-life balance hunter, Brigid Schulte, endeavors to wake up America to the mess we’ve gotten ourselves into by putting obsessive “busyness” and profits ahead of our kids, our spouses, and ourselves. Schulte deconstructs an American culture driven by a destructive sense of individualism and machismo that puts us on a never-ending treadmill — the unhealthy kind — as well as the policies and gender inequality that keep us there. She draws upon the experience of her own work and family life, and visits Denmark where the possibility of a better way reveals itself to her.
Health is influenced by social status — specifically, our position in the spectrum of autonomy and of full participation in society. The workplace is a microcosm for this “social gradient.” Epidemiologist and author Sir Michael Marmot, who has devoted his career to spotlighting the social determinants of health, led the Whitehall studies — investigations into the work lives and the health of thousands of British civil service workers. Whitehall II is among the most important studies of worker health, but — as with much of the excellent research from Europe and other countries around the globe — is noncommercial and, consequently, infrequently discussed at American wellness conferences. Sir Michael once wrote in Lancet,
Healthy behaviors should be encouraged across the whole of society. More attention should be paid to the social environments, job design, and the consequences of income inequality.
Of all the books in my pile, this is the one I most enjoyed reading. If it’s nothing else to you, it’s a heart-wrenching story well told. Triangle also is filled with historical detail about working life that, for many, will continue to resonate today. The importance of the Triangle Factory fire — along with the events that preceded it and those that ensued — remind us of the context for worker wellbeing, and how it represents something more profound than lower health care costs or even improved morale.
Worthwhile reading, but not in my pile:
Workplace Wellness That Works, by Laura Putnam. At this point in my career, I learn most by delving into topics that are unrelated or only somewhat related to wellness. I don’t own Laura’s book, but I flipped through a co-worker’s copy and found it to be thorough and well-researched. This is the book I’d recommend to someone who’s looking for wellness ideas or trying to assess the evidence basis for employee wellness.
Quiet: The Power of Introverts in a World That Can’t Stop Talking, by Susan Cain. Quiet raises consciousness about what life is like for the large segment — perhaps the majority — of employees who consider themselves introverts. This is relevant as we plan our wellness programs and events and target our communications. Quiet isn’t on my pile because I lent it to someone and never got it back. I’d like to think that’s some sort of endorsement.
Any text on occupational health psychology. I like The Handbook of Work and Health Psychology, but others will do. Just as we should understand health behavior if we want to influence employees’ exercise and eating habits, we need to learn the science behind stress, burnout, adjustment to change, resilience, depression, motivation, and engagement.
Even if we don’t always understand the science of worker health, we benefit from recognizing that there is science to worker health.
For those interested in evidence-based approaches to wellness, reading these or similar books will be a breeze this summer.
You look to your job not only for income and benefits, but also for purpose, social interaction, and daily routine. These influence your health, and the loss of them — or the threat of losing them — can suck the life right out of you.
Every day, millions of Americans either look for work or go to work. Their success at finding and/or maintaining a decent job with good benefits will, to a large degree, determine their current and future health.
Job loss, long periods of unemployment, and job insecurity have all been linked to deteriorating health. Yet, even companies that profess to support employee well-being have been known to contradict themselves by executing mass layoffs as a first line of financial defense rather than a last resort.
The Netflix exec who masterminded the vaunted slide deck about the company’s do-or-die culture boasted about the workers she’d laid off and fired. After being let go in 2015, she “doesn’t like to talk about it.”
Of course, layoffs aren’t the only source of unemployment and job insecurity…
Workers get fired due to performance problems.
Businesses go belly-up.
Some employers foster job insecurity as an ill-fated method to drive productivity.
But mass layoffs — regardless of whether they are euphemistically called reductions-in-force, redundancies, right-sizing, down-sizing, or all-around-the-town-sizing — are responsible for the majority of job loss that is out of workers’ control.
Job Loss and Health
Compared to employed workers, people who have recently lost a job are…
According to Gallup, Americans who have been unemployed for a year or more are more likely to be obese than those unemployed for a shorter time. The obesity rate rises from 22.8%, among those who have been jobless for less than three weeks, to 32.7% among those unemployed for a year or more. Those who have been jobless for more than 26 weeks are twice as likely to have high blood pressure and high cholesterol compared to people who have been unemployed for shorter periods.
Gallup also found that 20% of people unemployed for a year or more suffer from depression — about twice the prevalence compared to people unemployed for less than six weeks.
The Robert Wood Johnson Foundation points to several pathways from unemployment to deteriorating health:
Reduced income, which leads to inadequate nutrition, shelter, and health care.
Increased stress and limited access to the physical, mental, and social activity that are underpinnings of well-being.
Increased likelihood of engaging in unhealthy behaviors, like alcohol consumption, smoking, and drug use.
Job Insecurity and Health
The jury is still out on whether job insecurity — the threat of involuntary job loss — causes measurable declines in health status, but plenty of studies suggest a connection.
Job insecurity harms health, even more than unemployment.
One of the largest investigations of job insecurity and health analyzed data from more than 174,000 workers who were studied for nearly 10 years. It found that workers with job insecurity were 20% more likely to experience life-threatening heart disease compared to others who felt their jobs were a lock.
Job insecurity can lead to unhealthful behaviors like smoking, a Canadian analysis concluded, and avoidance of healthy behaviors like exercise and taking needed vacation and sick time off. It may even increase the risk of work-related injury and illness.
The relationship between job insecurity and health may depend on job type, economic conditions — how readily a laid off worker can land a new job — and workers’ attitudes about their employment and health. Case studies suggest that availability of social support and services for laid off workers may be differentiators for wellbeing.
Honeywell CEO Dave Cote doesn’t have a perfect record when it comes to worker well-being, but his decision to favor furloughs over layoffs during the Great Recession serves as a Harvard Business School case study on how to maintain competitive edge during economic downturns and recoveries. Cote’s process should be required reading for execs who succumb to arguments that layoffs are inevitable.
The benefits of using layoffs to manage costs during a recession didn’t make economic sense…
For workers in America, if you worked at a company like General Electric it’s more like you get a month’s salary and go. They lock the doors on the day you are fired. At Nokia there were people who knew they were going to be laid off in six months and were able to stay at Nokia with a Nokia email address with the Nokia laptop and spend time applying for new things, and Nokia helped them.
— Ari Tulla, laid off Nokia employee, now co-founder and CEO of BetterDoctor (quoted by BBC)
In a separate post, we’ll explore what we know about the relationship of health and on-demand or “gig” economy jobs, like Uber drivers, Airbnb hosts, Postmates couriers, and TaskRabbit taskers.
[If you’d like to comment on this post, please head on over to the LinkedIn version.]
Half of What I Know About Employee Health
I Learned from Concussion
Concussion is a movie about employee health as much as it’s about anything.
In the movie, the National Football League goes to great lengths to cover up the harm it allows to be inflicted on its players. The league is motivated by fear of liability and its unquenchable thirst for ever-increasing revenue.
Medical examiner Bennett Omalu, MD, a trained neuropathologist played in the movie by Will Smith, determines that several ex-players who died of unnatural causes suffered from chronic traumatic encephalopathy — CTE. The disease is characterized by long-term damage to specific sections of the brain, where tau proteins surround and choke off brain cells. The damage affects memory, agitation, and anger, and leads to dementia and, reportedly, Alzheimer’s disease. Brain studies were conducted on numerous players who died, including several who committed suicide. Ann McKee, a neuropathologist at Boston University’s CTE Center, reported in 2013 that she’d examined the brains of 46 former football players and found CTE in 45 of them.
Professional football players are employees of their respective teams, and the NFL serves as a sort of trade association for its member teams. For years, the NFL deflected blame for CTE, sometimes onto the players themselves. They pointed their finger to substance abuse (including steroids and alcohol), past history of concussion, and genetics. They downplayed the role of concussion, insisting that “mild traumatic brain injuries are not serious” and that players could safely return to the same game after suffering a concussion.
Ultimately, the NFL agreed to pay $765 million dollars in a settlement with more than 4,500 retired players who sued the league for concealing the issue. Speaking about the settlement, NFL Commissioner Roger Goodell said, “There was no admission of guilt. There was no recognition that anything was caused by football.”
The settlement included a provision that the NFL would never again compensate players or their families for CTE, which is why, as one example, the family of hall of famer Frank Gifford, diagnosed with CTE post-mortem in November 2015, cannot take action against the NFL.
Joe’s brain cloud and black brain mass, which viewers are led to believe result from job strain, are the stuff of satire. But is there really a chance that average workers exposed to prolonged job stress suffer brain damage — structural changes in brain tissue with accompanying symptoms?
Yes, there is.
Repetitive stimulation of the amygdala — a result of prolonged job stress — releases chemicals to the medial prefrontal cortex and may cause thinning of the cortex, enlargement of the amygdala and, consequently, a cycle of deteriorating stress modulation, cognitive symptoms, and impaired fine motor function.
In 2014, Ivanka Savic, MD, PhD of Sweden’s Karolinska Institute, published a study that used brain MRIs and showed that prolonged job stress — which included chronic overtime and a cycle of distorted perceptions regarding job demands, abilities, and control — leads to structural changes in the brain.
Compared to the MRIs of demographically matched control subjects, the patients who reported debilitating job stress — and exhibited burnout symptoms like impaired memory and concentration, sleeplessness, achiness, fatigue, and emotional exhaustion — showed abnormalities in the parts of the brain involved with the processing and perception of stress, specifically the prefrontal cortex and the cortex (which were abnormally thin) and the amygdala (abnormally large). These findings were consistent with Savic’s hypothesis that “repeated, chronic stress could lead to damage of the brain areas which modulate stress perception, leading to a vicious cycle with impaired ability to cope with stress.” The MRI findings were supported by documentation of reduced fine-motor skills and emotional regulation in the stressed group compared to the control subjects.
Finally, Dr. Savic concluded, “This condition needs to be considered as a stress illness, whose sufferers deserve proper and swift treatment.”
While a worker suffering from stress-related ailments may feel, as they go about their business, like they metaphorically are banging their head against a wall, the analogy between job-stress and football concussions is somewhat tenuous. Here are some ways the two phenomena differ:
The research on job-stress-related brain damage is still preliminary.
CTE is a result of smashed brains. Job-stress-related brain damage is more subtle, resulting from interactions between an individual’s job and their perceptions, and the resulting chemical activity in the brain.
There is no “cover-up” of job-stress-related brain damage that we know of — if for no other reason than most employers don’t know about it.
Job-stress-related brain damage has not been linked to behaviors that are as aberrant as those linked to repeated football concussions, nor has it been linked to death (though job stress has been found to be a significant risk factor for cardiovascular disease and death).
But there are some similarities, too:
Football concussions cause brain damage. Prolonged job stress also appears — based on preliminary research — to cause brain damage.
Just as football’s CTE was originally blamed on players (their drug use, history of previous head injury, or genetics), job stress in the United States has commonly been accepted to be solely a consequence of employee perception and coping skills, with employers turning a blind eye to their own role in creating job conditions that cause stress. Instead of empowering you with more control over your workflow, your employer adds a resilience program to your to-do list. In the absence of a broader preventive strategy, resilience programs are for job stress what football helmets are for concussions: Tools to help you endure more pain.
NFL players and everyday workers — as well as the enterprises that employ them — will benefit from having these neurological conditions identified and treated as early and effectively as possible.
Ultimately, symptoms of job-stress-related brain damage may prove to be less severe than CTE. But its burden to society — in terms of economics, well-being, and productivity — may be far greater simply due to the vastly larger population at risk.
The workplace demons that threaten employee health include long work hours, job insecurity, low job control, high job demands, shift work, effort/reward imbalances, role ambiguity, work-family conflict, inadequate workplace social support, and unfair treatment. These can be bucketed in various ways, but whatever you call them, they are the work conditions — controllable by employers — that research has consistently shown to influence employee health and well-being.
Now, along comes a study out of Stanford University that not only endeavors to quantify the burden — in terms of health outcomes, cost, and mortality — of these demons (what the researchers called “stressors” and I sometimes refer to as the workplace determinants of health), but also puts it into context relative to other, more commonly recognized, health issues.
Spoiler alert: More than 120,000 deaths per year and approximately 5% to 8% of annual healthcare costs may be attributable to how U.S. companies manage their workforce, according to this analysis. The mortality rate for these stressors, plus another the researchers found to have significant impact — lack of health insurance — was on par with the fourth and fifth largest causes of death in the U.S.: heart disease and accidents. It was greater than mortality resulting from diabetes, Alzheimer’s, or influenza.
Exposure to the following stressors was found to be more harmful than secondhand tobacco smoke:
Lack of health insurance
Low organizational justice (fairness)
High job demands
And — again, using secondhand smoke as a benchmark — the conditions that had a greater affect on mortality are:
Low job control
Long work hours
Lack of health insurance
The Stanford researchers concluded,
Employers may not make appropriate decisions concerning workplace management if they are unaware of the link between management decisions and employee health and healthcare costs. Our analysis suggests that for such organizations, paying attention to the structure of the workplace and the associated job stressors experienced by their employees may be a fruitful way to reduce unnecessary healthcare costs.
But they acknowledge that employers may have limited motivation to address these issues if, indeed, they’re not on the hook for the costs of health care — for example, in the cases of employees who have been laid off or who are not offered health insurance. The study didn’t delve into associations between stress and productivity.
The analysis was conducted by Joel Goh, Jeffrey Pfeffer, and Stefanos A. Zenios and published in Management Science. Goh is now on the faculty of Harvard Business School.
The researchers are conservative yet insightful in their expectations regarding the implications of their work:
While we stop short of claiming that employer decisions have a definite effect on these outcomes and costs, denying the possibility of an effect is not prudent either. Analyzing how employers affect health outcomes and costs through the workplace decisions they make is incredibly important if we are to more fully understand the landscape of health and well-being.
And what of our current approach to employee well-being, with its slaphappy embrace of screenings, health risk assessments, health coaching, apps, wearables and incentives? How does it jibe with the real determinants of worker health? Not very well, according to study co-author Jeffrey Pfeffer. In his YouTube interview for the Stanford Graduate School of Business, he says,
Employers worry mostly about individual decisions: eating, exercise, smoking, drinking…things like that. Or about policy issues like how we pay for health care. A lot of their excess health care costs come from what happens to people every day in the work environment… Things that employers could fix, if they wanted to.