Feature Article - Journal of Employee Assistance Vol. 48 no. 1 - 1st Quarter 2018
Project 95- Broadbrush Lessons for Today: Part II
By Jim Wrich
In this second installment of a three-part series, we continue to show the evolution of employee assistance into the EAP of today. Part I of this articles can be read online here http://www.eapassn.org/q4-17-Project-95-Broadbrush-Part-I (requires EAPA member login)
An Enduring Model
The Mineral Mining Division of Kennecott Copper Company in Ogden, Utah had pioneered a different approach. With a program called Insight headed up by Otto Jones, they focused strictly on job performance but the referral was made to Otto, who was a licensed clinical social worker and had deep knowledge of alcoholism. Supervisors focused on job performance and attendance and if regular disciplinary measures failed to correct the situation they referred the employee to the Insight program.
Otto then made a differential diagnosis and referred the employee to appropriate care in the community. By not affixing an alcoholism label on the program, it didn’t carry the stigma of previous workplace efforts. Otto found that about half the time the problem was alcoholism but with the rest of the participants it was some other disorder. However, utilization was so much higher than in the straight alcoholism programs that in absolute numbers, Insight was reaching more alcoholics.
Equally important, Otto wanted to know what difference Insight was making to the company. The overall improvement was stunning: a 52% reduction in absenteeism, a 74.6% decrease in weekly indemnity expense, and a 55.4% decrease in medical surgical costs. A few participants got worse and some stayed the same but a significant majority (77%) improved across the board.
The savings added up to several times the cost of the program. Years later when I was Director of the EAP at United Airlines (UAL) we found similar results and while about 40% of the participants had a substance use disorder, they accounted for the lion’s share of cost savings. Our benefit to cost ratio for the program overall computed to 7 to 1 over 5 years based on pre-post absenteeism alone.
Without discarding the Job Performance Focused Alcohol Identification approach, NIAAA advocated for the Broadbrush approach as well. OPCs were encouraged to propose whichever concept an employer was willing to adopt. Overall, Broadbrush emerged as the solid favorite. But it didn’t happen without a prolonged battle within the field as the Executive Director of National Council on Alcoholism led the charges against the Broadbrush approach. In short, he didn’t like the name and didn’t believe it would identify alcoholics. Behind the scenes, others at NCA supported the concept, Ross Von Weigand among them. When I asked him about titling my first book, “The Employee Assistance Program” he said, “It won’t turn anyone on, but it won’t turn anyone off, either.” The name stuck.
During the course of our training from NIAAA, we tackled other thorny issues, the most important of which was how we would know whether or not we were really doing any good, not only for the individual but for their employers and unions. The two major markers were recovery and participant utilization, which we referred to as penetration. We kept it simple. If 10% of the workforce suffered from alcoholism, we asked how long it should take to identify and refer a number equivalent to that population at risk. At that time, the US economy was largely industrial and turnover was much lower than it is in today’s predominantly service sector economy. So we informally thought the period should be about 5 to 7 years, resulting in an annual penetration rate of 1.5% to 2.0% per year for alcoholism referrals.
In Broadbrush programs we assumed that mental health and family problems also affected about 10% of the workforce so another 1.5% to 2.0% should be added to the utilization rate. Thus, many of us adopted a first-time annual employee utilization rate of 3% to 4% as a benchmark. This computed to about 30 to 40 first-time employee referrals per year per 1,000 employees, with 15 to 20 being assessed alcoholic. In addition, we believed a significant number of family members should be served. Turning to recovery, the Hazelden data indicated that a 50% benchmark first-time continuous recovery rate after one year with improvement in life functioning and life style was a safe expectation for employed alcoholics and many of us adopted that as a goal.
Later, Norm Hoffman, PhD. began an illustrious career at CATOR, an addiction treatment outcomes research firm in St. Paul, Minnesota. He developed a database of 75,000 adults and 11,000 adolescents, which continued to show that recovery was likely in a majority of cases if the right type, length, and level of treatment was provided.
It took a while longer to empirically document the benefits for employers but eventually Benefit to Cost Analysis was developed. Until then, the Insight data was the gold standard for many of us as we traveled our states talking to corporate and union leaders. Equally important were the positive anecdotal reports from supervisors and union reps along with a reduction in grievances and labor unrest. These satisfied even some of the most conservative managers as the Thundering Hundred implemented programs around the country.
We also thought it was important to declare what a Broadbrush program was not. It wasn’t industrial social work, industrial psychology or industrial medicine. It wasn’t a treatment program or in-house AA. It was neither a place to coddle poor performers or to trigger punishment. Persuasion not coercion was the key. The earliest definition of what Broadbrush was “… a labor-management control system designed to earlier identify problem employees when their problems impair job performance and motivate them to receive assistance to resolve the problem.” As time passed this definition was refined and methods were developed to attract and assist employees before their problems adversely affected their performance.
The heart of the program was A and R (Assessment and Referral). Finally, and most importantly, was the role and function of the person to whom employees with problems would be referred. With straight alcohol identification and referral programs the answer was easy: Usually it was a recovering alcoholic trained in motivational interviewing.
But in Broadbrush programs, the role and credentials were more complex. Someone who knew how to identify and refer alcoholics was still essential, but they also needed to have sufficient familiarity with a host of other mental health, family, and concrete issues to make an accurate assessment and an appropriate referral. Technically, they needed to professionally perform three tasks:
* Accurately assess a broad range of issues distinguishing between presenting and primary disorders,
* Bring the issues forth to the attention of the participant in a way that didn’t cause them to run out of the room, and
* Persuade participants to take action that they would not have been able to take on their own, without resorting to illegal leverage tactics by threatening their job if they didn’t comply.
One task we did not believe they should do was the treatment itself. We did not believe a single therapist could be competent to treat all of the disorders a Broadbrush program would attract. Moreover, if they got bogged down in delivering the direct care, we were concerned that they would not have time to handle new participants or the all-important follow-up and continuing care, which for chronic issues could include weekly sessions for a period of time.
We initially referred to them as Motivational Interviewers and later A and R resources. Very few professionals and virtually no recovering people were ready made for this role. While several dozen had emerged from the original Thundering 100 and the following group of NIAAA trainees, these numbers were miniscule in comparison to the hundreds and then thousands of workplaces that would eventually develop what were to become known as Employee Assistance Programs.
Mountains and Valleys
By 1975, we were riding high. Dozens of Fortune 500 companies were installing programs, insurance coverage was increasing, testimonials abounded, and positive data was accumulating. One might have believed that Broadbrush programs would always be a source of help for large numbers of alcoholics and other addicted people given their original objective, the support of NIAAA as the principal funding source, the initial makeup of the OPC group, the name of the field’s first professional association (The Association of Labor and Management Administrators and Consultants on Alcoholism-ALMACA), and the fact that some of the most compelling BCR data was based on the recovery of alcoholics.
Unfortunately, a number of conditions and events evolved over the years that militated to the contrary. Many great in-house Broadbrush programs – by then known as EAPs – emerged, such as Burlington Northern Railway, Bank of Montreal, Amoco, United Airlines, and a group that became known as the Employee Assistance Roundtable. But such programs became fewer and farther between and the alcoholism focus was all but lost in many of them.
Over the years, I have completed performance audits of dozens of EAPs. In some the rate of Substance Use Disorder (SUD) referrals is where we as OPCs thought it should be, about 1.5% to 2.0% of the employee population per year, first-time participants. But in many programs the penetration into the alcoholism population had fallen to less than the incidence of the problem in the general population, barely one-fourth of the standard we had set for ourselves in the mid-70s.
Yet, the disease certainly hasn’t disappeared. Since Don Cahalan’s landmark study, “American Drinking Practices” in 1967 through present day studies published by NIAAA, the rate of alcoholism and other drug disorders has remained at about 9 percent, or 1 in 11 in the general population, with men being higher than women. So, the question is, “What happened?”
The evolution of the Insight program provides a striking picture of what was to occur in the EA profession. Ever the entrepreneur, Otto Jones created a company, Human Affairs International (HAI), and began providing Insight to other employers on a contract basis. The company grew as the EAP concept caught on around the country and by the mid-1980s HAI was providing services to some of America’s largest companies. The need for competent assessment and referral staff surged. The problem was that few of them had Otto’s skills as both a clinical social worker and an expert in recognizing and intervening in alcoholism. Otto preferred MSW’ but like virtually all other health professionals, few had been trained in addictions and virtually none in the A and R function.
In the beginning, Otto himself trained them. But when HAI grew into a national organization it had to contract with hundreds and then thousands of MSWs and other professionals nation-wide in order to demonstrate to prospective customers that it had a sufficient national network to service their multi-state workforces. Otto couldn’t train them all.
Filling a Gap and Creating an Industry
In the meantime, a couple of bright young innovators, Carl Tisone and Richard Hellan in St. Louis formed PPC Worldwide Service in 1975, which became the world’s largest commercial EAP provider. Recognizing how few companies had adequate mental health benefits, PPC offered a unique approach in which their contracted EAP counselors would provide brief therapy to employees. In essence, those charged with assessing and referring were doing the treatment themselves.
Since some employers had more extensive mental health benefits than others, PPC provided service options based on numbers of EAP sessions ranging from 3 to 10. This was a great model for some problems such as financial, legal, family, and marital, for which brief therapy was appropriate. But because brief therapy isn’t generally suitable for most chronic issues including addictions, PPC’s policy was to refer participants with those issues to outside addiction treatment resources unaffiliated with PPC.
As national EAP referral networks were formed many individual A and Rs served multiple providers. Very few had the kind of training necessary to recognize and refer employees with alcohol problems. Instead, standard practice began to focus on the presenting problems, such as the marital, family and financial issues that can be caused by addiction. However, addiction itself was not generally addressed unless presented, which was rare. Experience has shown that A and Rs must be trained in how to effectively inquire about addiction to break through the denial inherent in the condition. This starts by asking every referral about their personal and family background regarding drinking and drug use patterns.
Other commercial EAP providers sprang up. Some addictions treatment centers that had been receiving referrals from in-house EAPs staffed largely by recovering alcoholics decided to get into the EAP business themselves so they could channel referrals into their own treatment programs. Many EA professionals considered this to be a conflict of interest that could compromise the integrity of the A and R process. The most logical group to protest would have been ALMACA, the field’s only professional association at the time.
But ALMACA itself had a conflict. Always strapped for money, a major source of its income was its annual conferences where most of the exhibitors and many attendees were sponsored by treatment centers. I recall commenting to Tom Delaney, who was the Executive Director of ALMACA, that I feared we would someday find that half of the EAPs were owned by treatment organizations trying to put everyone into inpatient treatment while the other half would be owned by insurance companies trying to keep everyone out. By the mid-1980’s most employees that had access to an EAP worked for employers that had contracted for service with a commercial provider.
It’s Gotta be Easier than That
There were exceptions to the commercial or external EAPs as they were called. At UAL in 1978 we developed an in-house service that was widely recognized by ALMACA and others as one of the premier programs in the field. About 40% of the referrals were for alcoholism and other drug issues. Many organizations sought our consultation. But when we described the arduous 3-year task to implement the program for 50,000 employees, including 160 two-and-one-half hour training sessions for 4,000 key management personnel including the CEO, most EAP inquirers opted for the “turn-key” service of a large commercial provider.
Soliciting proposals and managing a contract was much easier than the hands-on implementation and management required of a Director of a large in-house program, and it involved little direct hiring of A and R staff or key employee orientation and training. Unfortunately, the Assessment and Referral resources were largely untrained in addictions.
With rare exceptions, such as Dr. Dale Masi’s program at the University of Maryland, schools of social work, psychology, and medicine, taught virtually nothing about alcoholism and drug addiction. They certainly did not teach students how to intervene in the way an A and R needed to in order to function effectively. At UAL we found that in filling one A and R position, it was necessary to interview on average 10 candidates, and getting those 10 required weeding through more than 50 resumes.
The worst fears of the OPCs and organizations such as NCA were beginning to be realized. Literally thousands of therapists untrained in alcoholism and effective assessment and referral techniques were becoming the heart of the EAP world.
NEXT ISSUE: Trouble brewing in paradise.
Jim Wrich is one of the pioneers of Employee Assistance Programs (EAPs) - one of the original Thundering 100 who launched the modern EAP movement through Project 95-Broadbrush. In 1972, Jim implemented some of the first EAPs in the country. An early member of ALMACA, (later the Employee Assistance Professionals Association,) he served as First Vice President and was the founding President of the Employee Assistance Society of North America (EASNA). Since 1987 he has managed his own firm, J. Wrich & Associates, LLC. (JWA), a health systems performance company, which provides a broad range of consulting and cost analysis services to businesses and unions.