Psychology and Health log7, Vol. 1, pp. 237-255Photocopying permitted bv license only© 1987Harwood Academic Publishers GmbHPrinted in the United Kingdom

Worksite Stress Management:A Comparison of Programs

JAMES F. SALLIS TM, TRACY R. TREVORROW 2, CAROLYNC. JOHNSON 3, MELBOURNE F. HOVELL 4 and ROBERT M.KAPLAN 5

1University of California, San Diego, MO31F, La Jolla, CA 92093, USA2Department of Psychology, University of Hawaii, Honolulu,HawaE 96822, USA3Louisiana State University School of Medicine, 1440 Canal Street, Suite -t400, New Orleans, LA 701124Graduate School of Public Health, San Diego State University, San Diego,CA 92182, USASCenterfor Behavioral Medicine, San Diego State University, San Diego,CA 92182, USA

(Received 27 March 1987)

The purpose of this study was to compare the effects of commonly used approaches tostress management, delivered at worksites. Seventy-six volunteer employees wererandomized to a relaxation training group, a multicomponent stress management group,or an education/social support group. Measures were collected at baseline, after theeight-week intervention, and at a three-month follow-up. There were significant reduc-tions in anxiety, depression and hostility, which were maintained in all conditions. Nogroup improved significantly on job satisfaction, work stress, resting BP. or BPreactivity, to mental arithmetic or cold pressor stressors. There was no evidence that onegroup was more effective than the others. Psychological benefits may have been due tononspecific intervention factors. While decreases in hostility may be a health-relatedbenefit for all groups, it may be unrealistic to expect physiological improvements fromclinical stress management programs with nonclinical employee populations.

KEY WORDS: Stress management, blood pressure reactivity, worksite health pro-motion, hostility, relaxation training.

* Correspondence to: .lames F. Sallis, PhD, Division of General Pediatrics, Univer-sity of California. San Diego (M031), La Jolla. CA 92093, USA.

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_-38 J.F. SALLIS et aL

INTRODUCTION

Worksite stress management: a comparison of programs

Worksites have become a primary setting for stress managementprograms because of the convenient access to large numbers of people(Sallis et aL, 1986), and because the work setting is commonly viewedas stressful (Holt, 1982). Approximately 15-20% of large corporationsin California (Fielding and Breslow, 1983) and Colorado (Davis et aL,1984) offer stress management programs, and surveys of workers haveidentified stress management as a frequently perceived need (Niehoffand Romans, 1982).

Several studies have demonstrated that worksite stress managementprograms can produce improvements in psychological and physio-logical parameters, when compared to control conditions (Carringtonet al., 1980; Charlesworth, Williams and Baer, 1984; Patel, Marmotand Terry, 1981; Peters, Benson and Peters, 1977; Peters, Benson and

Porter, 1977). However, a number of questions remain unanswered,and the study reported here is designed to address these issues.

The first issue pertains to the assessment of the effects of stressmanagement programs. A comprehensive assessment approach wouldinclude measures of emotional and cognitive variables, as well asphysiological measures. In addition, studies conducted at worksitesshould evaluate the impact of programs on work-related variables such

as work stress and job satisfaction. In the present study three variablesshown to predict cardiovascular diseases were included to examine

possible health benefits of stress management: hostility (Barefoot,Dahlstrom and Williams, 1983; Shekelle et al., 1983; Williams et al.,

1980), blood pressure (BP; Pooling Project Research Group, 1978),and BP reactivity to stress (Keys et aL, 1971; Krantz and Manuck,1984).

A second methodological issue is the choice of appropriate controlconditions. Most studies have shown that stress management issuperior to wait-list conditions (Carrington et aL, 1980; Charlesworth.Williams and Baer, 1984; Murphy, 1984; Patel, Marmot and Terry.1981), but the one study that controlled for nonspecific effects foundno differences on psychological variables (Peters, Benson and Porter.1977). As the primary hypothesis guiding stress management programdesign is that specific skills-related interventions produce observedeffects, it is important to control for nonspecific effects with credible

WORKSITE STRESS MANAGEMENT 239

control conditions (Kazdin, 1980). Such a control group was includedin the present study.

Finally. the comparative effect of the numerous approaches to stressmanagement have gone unexplored. Thus, the purpose of the presentstudy was to compare commonly used approaches to stress manage-ment. Condition 1 emphasized a single component; relaxation train-ing. Condition 2 was a multicomponent cognitive-behavioral program.This condition emphasized relaxation training, cognitive skills andbehavioral skills (e.g. assertiveness). Condition 3 controlled for non-specific intervention effects and emphasized the value of learningabout the effects of stress and the value of social support in stress .....reduction.

METHOD

Design

This randomized controlled group outcome study compared threeintervention conditions: RelaxationTraining (RT), Multicomponent

Stress Management (MSM), and an Education/Support comparisoncondition (ES). Assessments were conducted at baseline, post-intervention, and three-month follow-up. The study was conducted attwo corporations, and the pooled results are reported.

Subjects

Subjects were employees of two "high tech" corporations in SanDiego, California, employing 1800 and 200 persons, respectively.Recruitment to orientation meetings was accomplished by posters in

high-traffic areas, notices in company newspapers, interoffice corre-spondence, computer mail and presentations at managerial staff meet-ings. The announcements invited those employees who felt stressed toparticipate in a study of stress reduction methods.

A total of 76 subjects (43 male, 33 female) completed baselineassessments and were assigned to experimental conditions. Twenty-sixwere assigned to the RT condition; 26 to the MSM condition; and 24 tothe ES condition. Group sizes at both corporations were very. similar.The participants were predominately Caucasian, married and well

educated. Nearly one-third had advanced degrees, and the mean age

240 J.F. SALLIS et aL

Table 1 Demographic characteristics of group participants

Variable Group

MSM RT ES

Male N = 17 (65%) N -- 15 (58%) N = 14 (58%)Female N = 9 (35%) N = 11 (42%) N = 10 (42%)Age (years)

Mean 37.8 37.4 34.4SD 8.8 9.3 9.5

Range 21-58 24-55 24-56Education (years)

Mean 15.9 16.3 15.8SD 1.3 1.6 2.0

Range 14-18 12-19 12-19Marital status

Married N = 16 (62°/) N --- 16 (62%) N = 14 (58%)Sep/div/widowed N = 2 (7%) N --- 8 (31% ) N = 7 (29%)Never married N = 8 (31%) N = 2 (8%) N = 3 (13%)

Years in companyMean 3.3 4.9 2.8SD 4.2 5.3 2.7

Previous stress

Management training 8% 15% 23%

was 36 years (range = 21-58). Approximately 20% had attended stressmanagement programs previously. Occupations ranged fromengineers and the corporate lawyer to secretaries and a maintenanceworker. All were free from medical problems or obtained physicianconsent to participate. Table 1 summarizes subject characteristics.

Procedure

At the orientation meeting, volunteers were scheduled for two pre-

intervention assessment sessions. At the first assessment subjects paid

$30, of which $10 was a materials fee and $20 was a deposit. Five

dollars was refunded for attending at least half of the sessions, $5 was

returned for attending the post-intervention assessment, and $i0 was

returned for attending the follow-up assessment.

Measurement

Subjects completed all measures at the three assessment points. Inaddition, an adaptation session for the physiological measures was

WORKSITE STRESS MAN,_GEMENT 241

conducted one week prior to the baseline assessment. All measure-ment sessions took place at the worksites.

Physiological measuresPhysiological measures were collected by students who were trained inall procedures, practised the entire protocol under supervision, andpassed the Hypertension Detection and Follow-Up Program video-taped blood pressure determination test (Curb et al., 1983). Aneroidsphygmomanometers were used in the measurement of BP. BPs weretaken with the subject's right arm resting on a table at heart level.

The stress responsivity assessment procedure was modeled afterthat of English and Baker (1983), using cold pressor and mentalarithmetic as stressors: (a) During the adaptation period subjects satquietly for at least 10 minutes in order for physiological responses tostabilize. (b) Two BPs were taken for the initial baseline. (c) For themental arithmetic task, subjects were read standard instructions and

waited during a 30-seconed anticipation interval. Subjects then seriallysubtracted a two-digit number from a four digit number for twominutes. BP was taken during the final 30 seconds of the task and againafter a two-minute recovery, period..At each assessment session (i.e.pre-, post-, and follow-up), the subtrahend and minuend were differ-ent. (d) Five minutes of quiet sitting allowed the BP to return tobaseline levels. Two BP readings were collected for the second base-line. (e) Subjects were read standard instructions for the cold pressortask and waited 30 seconds. Each subject immersed the left hand in ice

water (2--4°C) for 90 seconds. BP measurements were made during thefinal 30 seconds of the immersion. (f) Subjects sat quietly for two

minutes after removing the hand from the ice water and the final BPmeasure was taken.

Self-report measuresThe trait scale of the State-Trait Anxiety Inventory (Speilberger.Gorsuch and Lushene, 1970) was used to measure anxiety. Depression

was assessed using the 21-item Beck Depression Inventory (Beck etal., 1961). The MMPI Hostility subscale (Cook and Medley, 1954)served as an index of hostility.

A scale to measure perceived work stress has been developed

(Steinmetz, Kaplan and Miller, 1982), which allows subjects to rate thestressfulness of many job-related situations and conditions. It was

242 J.F. SALLIS et al.

hypothesized that a successful stress management program wouldproduce alterations in the appraisal of work stressors (Lazarus andFolkman, 1984).

An indirect measure of coping with work stressors was created byhaving subjects rate their confidence in coping with each of thestressful situations on the Work Stress Scale. Since self-efficacy per-cepts are believed to mediate coping responses (Bandura, 1977),evidence of increased efficacy in coping with work stress would be anindication of benefit from the stress management programs.

Job satisfaction was measured with a four-item rating scale based on

the factors of the Cornelt Job Description Index (Smith, Kendall andHulin, 1969). The items assessed satisfaction with work. promotions,co-workers and supervision.

Process measures

A number of supplementary scales were administered to examine theprocess of change. A credibility questionnaire adapted from Borkovecand Nau (1972) was administered after the first session and at the

post-assessment to examine the credibility, of the intervention ration-ale and the actual intervention, respectively.

Since the interventions being compared had some similarities andsome differences, it was important to determine whether the interven-tions were perceived as intended. Subjects rated the extent to which

each of 12 intervention components was emphasized in their group.

Interventions

Subjects met in groups of 11-16 persons for 8 or 10 weekly one-hoursessions. (Since the replication was conducted in the summer months,two weeks were added to the intervention to allow for vacation time.)Sessions were held either during the lunch hour or immediately afterworking hours on the subj ect's time. Two clinical psychology graduatestudents led each group. Both had experience and training in stressmanagement interventions, and they were supervised regularlythroughout the study.

All conditions had several common elements. In the first session, a

general introduction to the stress concept and the specific rationale foreach group was presented. Every session involved presentations bygroup leaders and group discussion. Each group received written

WORKSITE STRESSMANAGEMENT 243

materials and an audiotape. The differences among groups aredescribed below.

Relaxation trainingSubjects in the RT groups learned a sequence of five relaxationexercises, which progressed from time-consuming to very. brief tech-niques. The exercises were: (a) 16 muscle group progressive musclerelaxation (Bernstein and Borkovec, 1973); (b) four muscle grouprelaxation; (c) total body relaxation (i.e. tense all body musclessimultaneously then release); (d) deep breathing relaxation; and

(e) mental imagery. Subjects received a rationale for each technique,and one or more exercises were practised in each session. Briefpresentations were made on the benefits of regular relaxation forconditions such as headaches, hypertension and insomnia, and sup-porting handouts were distributed at each session. Audiotapes withinstructions for three of the exercises were given to all participants,and they were encouraged to practise some form of relaxation at leastonce a day. Relaxation logs were discussed and problem-solving wasused to identify and overcome barriers to practise. Discussioncentered around personal benefits of relaxation, and methods of

initiating and maintaining regular practice.

Multicomponent stress managementIn the MSM condition, the intervention was based on a model ot the

stress and coping process contained in an instructional manual (Foll-ick, Sallis and Fowler, 1981). It.was felt that providing a framework to?

organize one's thinking about stress and the use of stress managementstrategies would be helpful. Each week a manual chapter was distri-buted as well as an assignment based on the material discussed in thesession. The same relaxation sequence used in the RT condition wasfollowed, and the same relaxation audiotape was used. Presentationsand chapter topics included: identifying stress responses, using socialsupport, cognitive restructuring, changing Type A behavior, selectingcoping strategies, becoming appropriately assertive, and maintainingeffective coping habits. Each week a relaxation technique was prac-tised, a new skill was introduced, and homework was discussed.

EducationsupportOne emphasis in the ES condition was education about the harmful

244 .I.F. SALLIS et al.

effects of stress. This type of education is commonlv used in stressprograms to enhance awareness of stress and to motivate people toreduce stress. Presentations were provided on life events, interperso-nal stress, work stress, physiology of stress, and stress and heartdisease. Another emphasis was social support. The benefits of talkingto someone about stress were underscored, and the value of groupsupport in the session was highlighted. It was believed that these twoapproaches would be interesting, relevant and credible, but would notteach specific skills. The sessions were composed of 20-minute presen-tations, augmented by handouts and followed by unstructured groupdiscussion. An audiotaped lecture on the evolution of the stressconcept was provided. The group leaders were careful not to providebehavioral suggestions for managing stress to ensure that the essentialdifference between this comparison _oup and the RT and MSMgroups was the use of specific stress management techniques. ,..

RESULTS

Analysis of drop-outs

For each group the numbers of subjects who participated in each of thethree assessments are shown in Table 2. Five subjects were notassessed at post-test: two because of serious illness, and the othersbecause of business commitments, lack of interest or schedulingproblems. Seven more subjects were lost at the follow-up. Reasons fordrop-out were refusal (2), changed jobs (2), and scheduling problems(3). The percentage of subjects measured was 93% at post-test and86% at follow-up. While subjects who dropped out did not differsignificantly from those who completed the study on baseline depend-ent measures, they were more likely to be male and in the MSM group.

Table 2 Number of subjects who participated in pre-. post- and follow-up assessments.

Assessment Group

MSM RT ES Total

Pre 26 26 24 76Post 25 24 22 71Follow-up 23 22 22 67

WORKSITE STRESSMANAGEMENT 245

In the RT group 85% attended at least half of the sessions, while

73% of the MSM group and 96% of the ES group attended at least halfthe sessions.

Differences between groups at baseline

Oneway ANOVAs revealed no differences at baseline between groupson any dependent measure, age. education, or years with the com-pany. Chi-square analyses revealed no baseline differences betweengroups on gender or marital status.

Changes in dependent measures

A series of 3 × 2 (group × time) repeated measures ANOVAs wereused to evaluate the effects of interventions on outcome variables.

Differences between baseline and post, and between baseline andfollow-up were analyzed separately. Systolic BP and diastolic BP wereanalyzed under six conditions: first baseline, mental arithmetic reacti-

vity and recovery., second baseline, cold pressor reactivity and recov-er. Group means and standard deviations for all dependent measuresat each assessment are presented in Tables 3, 4 and 5.

Self-report measures

Scores on trait anxiety, depression and hostility indices were near thepopulation means in each instance. Significant main effects for timewere found for trait anxiety, depression, hostility and work stressself-efficacy. Anxiety decreased in all groups from baseline to follow-up, F (1, 61) = 5.99, P < 0.017. Depression was significantly lowerthan baseline in all groups at post-test, F(1, 66) = 9.71, P < 0.017, andat follow-up, F (1, 61) = 7.62, P < 0.008. Hostility was significantlylower than baseline at both post-test, F(1,65) = 11.52, P < 0.045, andat follow-up, F(1, 60) = 12.57, P < 0.02. Total work stress self-efficacydecreased significantly in all groups between baseline and follow-up, F

(1, 59) = 6.36, P < 0.014. There were no significant changes inperceived work stress or rated job satisfaction.

Physiological measuresThe mean resting BPs were similar to what would be expected for agroup of this age and gender composition, except that the diastolic BP

246 J.F. SALLIS et aL

Table 3 Mean (and standard deviation) of psychological measures at each assessment foreachgroup. ..

Measure Assessment Group

MSM RT ES

Trait Pre 38.2 (6.8) 40.0 (7.8) 36.5 (9.5)Anxiety Post 37.2 (7.91 38.7 (7.7) 35.7 (8.3)

Follow-up 36.4 (7.2) 37.0 (7.7) 35.4 (8.5)Beck Pre 7.2 (5,0) 5.9 (4.8) 5.6 (5.4)Depression Post 4.3 (3.7) 5.3 (5.6) 4.7 (4.7)Score FoUow-up 4.4 (4.4) 4.0 (6,7) 4.8 (4.3)MMPI Pre 17.5(5.9) 18.2(5.3) 16.4(5.5)Hostility Post 16.4(7.0) i6.6 (6.6) I5.5(6.6)Score Follow-up 13.6 (6.3) 16.3 (6.1) 15.9 (7.2)Total perceived Pre 91.9 (19.7) 86.7 (22,1) 88.6 (28.0)Work stress Post 98.3 (21.4) 91.9 (25.8) 88,1 (28.7)

Follow-up 91.7 (24.7) 92.8 (30.6) 89.9 (37.2)Totalworkstress Pre 3.3 (0.4) 3.5 (0.5) 3.6 (0.6)Serf-efficacy Post 3.4 (0.5) 3.5 (0.5) 3.7 (0.5)

Follow-up 3.2 (0.6) 3.1 (0.5) 3.2 (0.7)

Table 4 Mean (and standard deviation) ofsystofic blood pressure at each assessment foreach condition.

Measure Assessment Group

MSM RT ESn=26 n=26 n=24

1st baseline" Pre I16.5 (12.7) 113.9 (14.9) 115.5 (16.0)Post 115.3 (14.1) 114.3 (14.6) 113.9 (14.9)Follow-up 119.1 (14.3) 114.3 (12.6) 118.1 (16.0)

Mental arith. Pre 123,9 (14,9) 117.7 (17.0) 122,5 (20.6)

Reactivity Post 120.8 (15.7) 118.4 (15.5) 117.7 (14.4)Follow-up 126.8 (14.2) 118.8 (14.8) 121.9 (17.0)

Mental arith. Pre 115.9 (13.6) 113.1 (16.4) 114.9 (17.0)Recovery Post 113.8 (14.5) 111.7 (I7.5) I13.9 (I4.0)

Follow-up 119.0 (13.9) 114.9 (13.9) 116.1 (15.6) .2rid baseline _ Pie 115.4 (12.0) 112.7 (16.3) 113.9 (15.8)

Post 112.7 (12.6) 112.3 (15.7) 113.3 (14,8)Follow-up 118.1 (14.9) 115.0 (14.2) 115.6 (16.2)

Cold pressor Pre 133.4 (15.3) 129.1 (19.8) 129.7 (20.2)Reactivity Post 128.3 (19.1) 131.6 (22.0) 128.0 (17.5)

Follow-up 135.3 (21.0) 128.9 (18.9) 126.5 (15.6)Cold pressor Pre 117.5 (13.0) 114.1 (16.8) Ii5.2 (16.8)Recovery Post 113.9 (14.4) 114.4 (18.7) 113.2 (14.2)

Follow-up 121.8 (13.7) !15.5 03.0) 115.7 (16.1)

a Mean Of two TcadJngs.

WORKSITE STRESS MANAGEMENT 247

Table 5 Mean _and standard deviation) of diastolic blood pressure at each assessment foreach condition.

i Measure Assessment Group

MSM RT ESn=26 n=26 n_24

1st baseline_ Pre 69.4 (11.5) 71.0 (10.8) 70.8 (12.3)Post 75.8 (9.6) 70.1 (10.t) 72.3 (12.9)

Follow-up 77.3 (11.2) 67.8 (9.6) 71.2 (12.1)Mental arith. Pre 75.2 (10.8) 75.0 (9.6) 75.8 (12.6)

Reactivity Post 78.8 (11.1) 71.9 (11.4) 75.9 (12.3)Follow-up 79.5 (11.7) 71.9 (9.6) 75.3 (II.1)

i Mental arith. Pre 72.0 (11.8) 72.2 (11.4) 70.8 (13.2)I Recovery Post 74.5 (11.7) 69.2 (11.7) 73.9 (14.5)! " Follow-up 76,8 (10.2) 67.2 (8.9) 70,3 (12,6)i 2rid baseline" Pre 70.4 (10.1) 71.1 (10.8) 69.3 (14.1)[ Post 73.5 (I0.9) 70.5 (10.8) 72.8 (11.6)! Follow-up 75.1 (11.5) 68.2 (8.9) 69.7(12.2)

I Cold pressor Pre 86.3 (10.0) 85.2 (10.4) 83.6 (10.6)Reactivity Pos! 84,9 (12.2) 85.3 (14.5) 83.8 (11.8)

Follow-up 87.3.(13.2) 80.6 (12.7) 82.8 (10.1)Cold pressor Pre 71.5 (10.4) 72.7 (10.5) 70.5 (14.4)Recovery Post 74.5 (10.4) 72.3 (12.5) 72.6 (10.8)

Follow-up 79.4 (9,1) 69.4 (8.7) 71.7 (12.1)

• Mean of two readings.

was slightly lower than the expected norms (Department of Health andHuman Services, 1980). Expected BP increases during stress were

{ observed, with greater reaction to cold pressor than to mental arithme-tic. In general, BPs returned to near baseline levels at the recoverydetermination.

Analysis of systolic BP measures indicated no significant time maineffects, no significant group main effects, and no significant interac-rio'as at either the post-test or follow-up assessments.

There was a main effect for time for diastolic BP at post-test, F (1,

68) = 7.14. P < 0.01, and a group x time interaction at follow-up, F(2,68) = 3.24, P < 0.05. Neuman-Keuls follow-up tests revealed thatdiastolic BP in the MSM group increased significantly from baseline topost-test and remained higher at follow-up. There was a significantincrease in diastolic BP recovery from cold pressor for all groups, F(1,65) = 4.88, P < 0.03, and this was accounted for primarily by the MSMgroup. There was a significant group x time interaction for recoveryfrom cold pressor at follow-up, F (2, 57) = 3.20, P < 0.05. Follow-up

248 J.F. SALLISet al.

analyses revealed that the MSM group significantly increased diastolicBP during recovery, from cold pressor.

Because there are several ways to analyze reactivity data (Krantzand Manuck, 1984), the physiological data were reanalvzed. Within-session change scores were analyzed by ANOVA and analyses ofcovariance, with age as the covariate. In both cases, the results wereidentical to those reported.

Use of relaxation

Subjects in the MSM and RT groups reported on their relaxationpractise, and the results are presented in Table 6. During the pro-gram, 45% reported daily practice, but during the follow-up perioddaily practise dropped to 18%, and nearly 50% did not practise evenonce a week. Differences in frequency of practise between MSM andRT subjects were nonsignificant.

When asked to report which relaxation technique was used most

frequently, deep breathing relaxation was cited most often (45%),followed by four muscle group relaxation (22%), total body relaxation(15%), and use of imagery (15%). Only one subject used the 16muscle

group relaxation exercise most frequently.Subjects reported their main reason for using relaxation, and 39%

stated they used relaxation to relieve both general tension and tensionresulting from specific situations; 19% used relaxation to relieve or

prevent general tension; and 17% used relaxation in response tospecific events. Twenty-five percent of subjects reported they did notsystematically use relaxation.

Table6 Reportedrelaxationusefor multicomponentstressmanagementandrelaxationtrainingsubjects combined.

Frequency >I Day Daily 3 x Week 1 × Week <1 Week

Duringprogram 8.1% 37.8% 29.7% 16.2% 8.1%

Postprogramto follow-up 10.1% 8.1% 21.6% 10.8% 48.6%

Techniques 16 4 Total Instant/used Muscle Muscle body breathing Imagery

Percentage 3% 22% 15% 45% 15%

WORKSITE STRESSMANAGEMENT 249 '

Credibility analysis

Oneway ANOVAs revealed significant differences among groups atbaseline on credibility, F (2, 54) = 3.24, P < 0.05. Pairwise contrastsshowed that credibility was significantly higher for the MSM group. Atpost-test, there were also significant differences between _oups, 1:(2,68) = 17.38, P < 0.001. Credibility in the ES group was much lowerthan in the other groups. Overall scores at baseline indicated goodcredibility of intervention rationales, with a mean score of 25 out of apossible 36. At post-test, the credibility score for the ES group hadfallen to 15.

Intervention component analysis

Ratings of the emphasis placed on various intervention componentsconfirmed that the interventions were perceived as intended. Eachcomponent was rated on a 1-5 scale, and all of the differences between

groups were consistent with expectations. Both the RT and MSMgroups were significantly higher in emphasis ratings on the followingcomponents: practice exercises, relaxation techniques, maintaininglogs, and maintaining the. stress management program (all P <0.0001). The MSM group was rated significantly higher than the RTand ES groups on selecting coping strategies and the role of thou_ts instress (P < 0.0001). The ES group was rated significantly higher thanthe RT and MSM groups on educational information and importanceof social support (P < 0.0001). There were no significant groupdifferences on written information or stressor preparation.

DISCUSSION

This randomized controlled study of worksite stress managementprograms found that no intervention was more effective than theothers in changing any of the psychological, work-related or physio-logical variables that were measured. For this nonclinical population,the results are consistent with an interpretation that nonspecific inter-vention factors produced significant improvements in psychologicalfunctioning, but there were no improvements in work-related vari-ables, BP or BP reactivity to stress. Subjects in all groups decreasedhostility scores, indicating that even this nonclinical population experi- •enced some health-related benefits.

250 J.F. SALLIS et aL

Since there were no apparent benefits of the skills trainingapproaches over the educatiorv'support condition, it appears thatnonspecific factors such as attention from leaders and group supportmay be responsible for the observed changes. This nonspecificityinterpretation was strengthened by ratings that indicated that differ-ences between interventions were perceived as intended. Since theratings of components were in line with predictions, there is evidencethat the group leaders delivered very. different interventions, whichnevertheless produced very similar results. An alternative explanationof the findings is that the education/support groups did teach usefulskills. This possibility cannot be ruled out because (a) stress manage-ment skills were not directly measured, and (b) there was no wait-listcontrol group.

These findings seem to indicate the importance of including condi-tions that control for nonspecific intervention effects when evaluatingbehavioral interventions. Use of only wait-list control conditions canlead to possibly unwarranted conclusions regarding the mechanism ofobserved effects. However, in this study, a no-contact condition wasnot included, and two additional alternative explanations of thefindings must be considered: effects of repeated testing and regressionto the mean. It is unlikely that repeated testing would account forreductions in emotionality, because in other worksite stress manage-ment studies with normal populations, psychological measures did notchange significantly in control subjects (Carrington etal., 1980; Peters,Benson and Porter, 1977). It is very. unlikely that regression to themean accounted for observed changes, because baseline values werevery near the means of the normative samples on all psychologicalvariables. Thus. it is impressive, given the average baseline values,that significant decreases were found in trait anxiety, hostility anddepression. It appears that the effects are real, but the importance ofsmall reductions from already normal levels is unclear.

Very little research has been conducted on the effect of relaxationon BP reactivity, but the results of this study are similar to previous

findings. The average BP reactivity to cold pressor was approximately15/14 mmHg, which is comparable to results of English and Baker(1983), even though subjects in that study had higher resting BPs.English and Baker found differences in reactive BP at post-test,adjusted for pre-test values, between relaxation and control groups.

i However, this difference was accounted for by an increase in the

WORKSITESTRESSMANAGEMENT 251

control group, not by a decrease in the relaxation groups. Thus. thereis no indication from this study that stress management or relaxationinterventions reduce BP reactivity to stress.

Interpretation of the lack of intervention effects on reactivity tomental arithmetic must include awareness that reactivity to this stimu-lus was lower than expected. Reasons for this minor anomaly are notapparent, but it would be difficult to produce decreases from such alow initial level of reactivity. Although BP assessors were carefullytrained and certified. BP measurement was conducted manually. Thereliability of measurement of BP reactivity in this study is unknown,although in another study by this group using trained student assessorsthe inter-observer reliability for resting BP was 0.87 for systolic BP and0.79 for diastolic BP (N = 53) (Patterson et aL, in press). However, nodata are available on reliability of assessment of BP during stressfultasks.

There were no changes in perceived work stress or job satisfaction,suggesting that attitudes toward work were not changed. Thus, therewas no evidence of direct benefit to the employer but. indirectly,reduction of hostility, anxiety and depression in employees is a benefit.One apparent negative impact of the interventions was the decrease inself-efficacy to cope with work stress among subjects in all _oups.

The BP results suggest that little or no change in BP should beexpected in nonclinical populations and that BP reactivity is notreliably affected by relaxation. Seventy-five percent of participants inthe RT and MSM groups reported practising relaxation at least threetimes a week during the intervention, so the lack of effect on BPmeasures is probably not due to low adherence. However, theseresults call into question the value of stress management programs fornormotensive volunteers. These results do not detract from consistentfindings that relaxation training significantly reduces BP in hyperten-sives (Agras and Jacob, 1979), and several studies have demonstratedthat worksite stress management for hypertensives can be effective(Charlesworth, Williams and Baer. 1984; Patel, Marmot and Terry,1981).

Kottke and colleagues (1985) argue persuasively that the only way toprevent most of the cases of cardiovascular disease in the US is toreduce the mean BP of the entire population, rather than lower BPs ofvery. high-risk cases. This model argues for general population-focusedprograms such as worksite interventions. However, despite a con-

_2 J.F. SALLIS et al.

siderable time investment, there were no detectable decreases in

resting or reactive BP in any group. While there was no evidence ofshort-term benefits, it is possible that stress management programs willproduce long-term benefits in slowing the usual age-related rise in BP.However. this seems unlikely, due to the dramatic drop in relaxation

practice reported during the follow-up interval. Intensive clinicalstress management programs may not be appropriate for nonclinicalpopulations. However. decreases in hostility, a consistent predictor ofcardiovascular disease mortality, suggests there were modest health-related benefits from all programs.

Comments from participants and inspection of credibility ratings areinformative. Participants in the ES group rated their intervention asmuch less credible at post-test than at baseline. They complained thatthey were not being given specific techniques to use in managing stress.Despite this, they reported the same psychological improvementsas those in the other groups. Employees in the MSM condition statedthey enjoyed learning the numerous techniques, but they felt over-whelmed by the amount of material, and there was some indication ofincreases in BP. Our expectation that the multicomponent approachwould allow people to choose favoured techniques from the severalthat were learned was incorrect. While this "cafeteria" approach is

commonly used in practise, it may not offer the expected advantages.The observed BP increase in the MSM group may be reflective of thedemands of their intervention, or it may be a spurious finding. The RTgroup participants were generally satisfied with their experiences.

This study was designed to reflect the .practise of stress managementin the business community. The RT and MSM interventions are similarin content and format to programs that are being conductedthroughout the country. Participants were recruited from the generalemployee population, and group leaders were at the master's level:Therefore, the results of this study should provide some insight intothe types of results that can be expected from the wpical worksitestress management program. However, present findings will not applyto programs that are offered to clinical groups, such as hypertensives.In the current study, there were modest decreases in emotionality

among all participants, indicating there are some psychological bene-fits to participation. The only apparent health benefit was reducedhostility. No direct work-related benefits were documented. Resultsfrom the present study and previous research (Peters, Benson and

WORKSITE STRESS MANAGEMENT _3

Peters. 1977; Drazen et al., 1982) provide little evidence that stress

management programs based on a skills-training model are superior to

placebo conditions. It is recommended that future studies investigatethe feasibility of low cost. low intensity, stress management programs

for normotensive employee populations.

Acknowledgements

The authors would like to express their appreciation to Dr Gary. Frost and Dr GloriaBader of Cubic Corporation and to the management of Calma Corporation for theirassistance and cooperation.

Dr Michael J. Follick provided helpful comments on an earlier draft of this manu-script.... "

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