British Journal of Addiction 7a (1983) 291-303© 1983 Society for the Study of Addiction to Alcohol and other Drugs,

Employee Assistance Programming: In Search ofEffective Interventions for the Problem-DrinkingEmployee

Keith Walker and Martin Shain*Addiction Research Foundation, Toronto

SummaryA critical review is made of traditional approaches to occupationally-based alcoholism programmes(Employee Assistance Programmes: E.A.Ps). Methodological problems in E.A.P. research arebriefly reviewed and major conceptual, ethical and practical difficulties underlying E.A.P. implemen-tation are identified. Suggestions for improving the efficacy and efficiency of E.A.Ps include: (i) theintegration of alcoholism services with more effective systems of employee performance-managementand (ii) the extension of E.A.Ps to include interventions aimed at the 'non-alcoholic' problem-drinkingemployee.

Occupational programmes aimed at assisting the problem drinking employeehave gained wide popular appeal across North America over the past decade orso. Although a number of versions of occupational programmes exist and areknown by a variety of names, procedurally they can be identified as falling intotwo major camps: the 'alcoholism only' approaches and the 'broad-brush'approaches. Employee Assistance Programmes (E.A.Ps) ofthe 'alcoholism only'variety, advocated most strongly by the National Council on Alcoholism(N.C.A.), usually stress the identification of the problem-drinking employeethrough declining work performance and the application of 'constructive coer-cion' to motivate him to accept assistance for his drinking problem. The 'broad-brush' approaches, more often associated with N.I.A.A.A. initiatives, viewalcoholism as just one of a variety of personal problems that can interfere withwork performance and usually place greater emphasis on the provision of assis-tance on a voluntary basis. While many very strong claims have been made forthe efficacy and efficiency of both types of E.A.Ps, the validity of some of thoseclaims has been challenged in more recent reviews of the occupational program-ming literature [1,3, 25, 27, 60]. Moreover, the major E.A.P. approaches wouldappear to be plagued by a number of conceptual, ethical and practical difficultieswhich seriously limit their applicability to some work settings.

Methodological problems in E.A.P. ResearchMajor methodological difficulties in E.A.P. outcome studies and proceduralincompatibilites among E.A.P. implementations make it impossible to rendervery confident judgements about the overall effectiveness and utility of E.A.P.

'Requests for reprints should be forwarded to Mr Martin Shain, Addiction Research Foundation, 33 RussellStreet, Toronto, Ontario, M5S 2S1,

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approaches to the problem-drinker. Studies have differed widely in (A) the par-ticular procedures and structure of the E.A.P. under investigation, (B) thecharacteristics ofthe employee populations under study, (C) the criteria adoptedto judge successful outcome, and (D) the types of research design adopted.

Procedural variations in E.A.Ps

While the ideal 'E.A.P. model' is frequently presented by its proponents as auniform set of procedures, there is in actuality no single, generally accepted set ofmethods for conducting an E.A.P. E.A.Ps differ widely not only in programmeemphasis (i.e., alcoholism-only vs. broad-brush approaches), but also in (A) theextent to which corrective procedures are introduced prior to the referral totreatment, (B) the type, amount and timing of coercion exerted on the problememployee to accept treatment, (C) the type and intensity of alcoholism treatmentsto which referrals are made, and (D) the degree of supervisory follow-up aimed atmaintaining compliance with organizational or rehabilitative objectives. SomeE.A.P. consultants stress the use of 'constructive confrontation' aimed at shapingup job performance more than they do 'constructive coercion' aimed at elicitingcompliance with treatment referral expectations. They advocate the use of aseries of corrective interviews with the problem employee, where the emphasis ison the careful documentation of his short-comings, the clear communication ofchanges required and the threat of disciplinary action in the event that change isnot forthcoming. Treatment referral, in such cases, is frequently regarded as afinal resort for employees who fail to respond to initial corrective steps. Generallythe trend among 'broad-brush' approaches, however, has been to de-emphasizeconstructive confrontation in favour of self referral, peer referral and referralthrough increased programme awareness. N.C.A. has tended to be critical of thattrend and some authors (e.g. [52]) have suggested that it more reflects the vestedinterests of the helping professions than it does the needs of the employedalcoholic.

The types of alcoholism treatment advocated and the relationship of theE.A.P. to treatment agencies vary widely from company to company [46]. fnsome larger organizations, treatment resources are an integral component of theE.A.P., but most rely on existing treatment facilities within the community, suchas inpatient or out-patient alcoholism units in general hospitals or communitymental health centres, A.A. groups, private clinics, and half-way houses. SomeE.A.P. workers (e.g. [15]) suggest that intensive, inpatient services are usuallyunnecessary and rely heavily on A.A. or out-patient referrals - and, in somecases, 'treatment' consists of little more than a visit to the company physician.Other E.A.Ps (particularly those associated with the N.I.A.A.A. initiatives andthe 'broad-brush approach) are quite programme-expansive in nature andattempt to provide the employee and his family with a broad range of counsellingand treatment services.

Employee population characteristicsE.A.P. studies have been conducted in different types of organizations, represent-

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ing a large variety of occupational groups. However, little attention has been paidto the role of employee characteristics, despite the fact that alcoholism rates havebeen found to vary widely among occupations [40, 47, 48] and despite the factthat subject characteristics such as age, sex, socioeconomic status and degree ofalcoholic impairment have been found to be more consistent predictors of out-come than have treatment variables (e.g. [5]). Whether variations in E.A.P.referral and outcome rates across organizations reflect differences in programmeeffectiveness or differences in employee characteristics is, thus, largely a matterfor conjecture. However, it is possible that favourable outcomes attributed toemployee characteristics are partly a product of interactions between thesecharacteristics and specific interventions carried out in the workplace. The statusof 'being employed' has been associated with favourable outcomes in treatment,but the term conceals a variety of pressures and supports which significant peoplein the workplace bring to bear on the referred employee. These pressures andsupports can be hypothesized to contribute to whatever favourable outcomeshave been observed among employed people. Thus, the workplace can be viewednot merely an agency of referral but also as an active force in the rehabilitativeprocess itself [64].

Inadequacies in outcome criteriaThe outcome criteria selected to assess the impact of E.A.Ps have typically beenrestricted to job-related indices such as job retention or reductions in absenteeismand accident rates. Outcome criteria relating to drinking behaviour or psychoso-cial adjustment are very rarely applied. Even so, ambiguities concerning themeaning of job-related indices make interpretations of findings difficult {cf. [50]).Absenteeism, for example, can be defined in very different ways (e.g. absentfrom job vs. absent from one's post; absent with vs. without leave) and job reten-tion need not necessarily reflect a positive outcome, since employees who con-tinue to be problematic can be disposed of in ways other than firing (e.g. demo-tions, lateral transfers, early retirement, long-term disability, witholding ofadvancement). Moreover, lengths of follow-up periods, when given, have variedwidely from study to study, and information concerning cases missing at follow-up has typically not been included in the evaluation of outcome.

Research design problemsBecause of organizational constraints, most E.A.P. evaluations have been basedon simple pre-post comparisons. Very few studies have employed a researchdesign that would allow for the assessment of outcome relative to a comparableuntreated control group [1, 25, 60]. No studies have attempted to determine thecomponent(s) of the E.A.P. (i.e. identification, confrontation, treatment) towhich observed outcomes can be attributed [1, 25, 60].

Conceptual and ethical difBcultiesE.A.Ps can be criticized on a number of conceptual, ethical and practical,

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grounds. The major themes underlying most E.A.Ps are (A) that alcoholism andproblem drinking constitute a progressive illness or disease, (B) that alcoholismwill almost invariably manifest itself in the workplace in the form of deterioratingjob performance, usually far in advance of any physical symptoms of the disease,and (C) that confronting the alcoholic employee with evidence of his deteriorat-ing performance, and offering him constructive organizational support forrehabilitation and treatment, will usually restore him to the role of a sober, func-tioning and valued employee.

Alcoholism is a treatable diseaseBelief in the disease concept of alcoholism and in the value of alcoholism treat-ment of one kind of another would appear to be more articles of faith than empir-ically testable assumptions to the major groups of E.A.P. advocates - indeed,statements of those beliefs typically appear prominently within company E.A.P.policy statements. Rarely is any evidence offered for the disease concept beyondmere appeals to authority, such as the A.M. A. definition of alcoholism (e.g. [23].Some authors (e.g. [3, 39]) have suggested that the commitment of the 'alcohol-ism industry' to the disease concept of alcoholism can be traced to its close politi-cal and historical ties with A.A. and the early alcoholism movement and havenoted that promotion of the concept has been instrumental in generating publicsupport and funding for alcoholism programming. In the case of E.A.Ps, theinclusion of alcoholism treatment in the company's medical insurance policy istypically viewed as critical to their successful functioning. Moreover, there is atendency among insurance companies to offer coverage for alcoholism treatmentonly under medical, in-patient auspices [21]. This practice in turn tends to per-petuate the disease model of alcoholism. Other authors (e.g. [4, 53]) havepointed to the inherent ethical dangers of premature labelling and referral totreatment that can result in the adoption of a sick role and the generation of aself-fulfilling prophecy. Such dangers are particularly troublesome in E.A.Ps, whichstress early identification.

Most E.A.P. advocates simply ignore the accumulating body of evidence inthe alcoholism literature suggesting that spontaneous remission and recoveryrates among alcoholics (and particularly among employed alcoholics) might bemuch higher than they were once presumed to be, that remission rates followingtreatment appear to be unrelated to the type, duration or intensity of treatment,and that only rarely do post-treatment remission rates appear to exceed those ofspontaneous recovery (e.g. [5, 8, 14, 17, 19, 20, 26, 49, 51]).

While E.A.Ps appear to be quite successful once identification and referralhave taken place, the strong possibility exists that it is the process of identifica-tion and confrontation, rather than any treatment or rehabilitative efforts, that isresponsible for the observed outcomes. Many E.A.P. advocates have stressed therole that 'crisis creation' through the threat of job loss may play in motivating theproblem employee to accept treatment, but little attention has been paid to theeffects of the increased level of supervisory scrutiny that invariably accompaniesconfrontation, referral and post-treatment follow-up. Rarely is any informationpresented in E.A.P. studies concerning the proportion of problem employees who

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respond to initial disciplinary efforts. However, at least two evaluative studieshave found that the success rate of identified problem drinkers referred to treat-ment was not very different from the success rates of those refusing a treatmentreferral [45] or of those who were not offered a treatment option [11].

Job deterioration as an early indicator of alcoholismThe prevalent theme in most E.A.P. advocacy literature - namely, that job per-formance deterioration is a reliable early indicator of advancing alcoholism - hasbeen challenged in recent E.A.P. reviews (see, especially, [60]). Much of the evi-dence used to support the claim has come from the documentation of cases refer-red to treatment for reasons of declining job performance. Typically, statistics arecompiled to demonstrate the high absenteeism or accident rates of alcoholic refer-rals relative to those of the organization as a whole (or, less often, relative tothose of a matched control group), and evidence is presented for a dramatic dropin those rates following referral. However, since E.A.P. referrals normally accountfor only a small fraction of the probable alcoholic population within most organ-izations with active E.A.Ps, it is difficult to know the extent to which one cangeneralize such findings to other alcoholics within the workforce. An accuratepicture of the actual relationship between alcoholism and job performance would,of course, require reliable information concerning the prevalence of alcohol abusewithin an organization as well as job performance documentation. Unfortunately,most of the published alcoholism prevalence estimates have been largely guesses,based on estimates of alcoholism within the population at large (cf. [57]), eventhough it is known that alcoholism rates can vary widely among different types ofindustries.

It is notable that, in the Labor-Management Alcoholism Journal (a bi-monthlypublication of the National Council on Alcoholism), occasional references aremade to an extensive series of in-plant studies carried out by the N.C.A. in theearly 1960s which, purportedly, demonstrated a clear and simple relationshipbetween the onset of alcoholism and a pattern of declining job performance — buta telephone call to the editor of the Journal requesting documentation revealedthat the findings of those studies had in fact never been published.

Shain & Groeneveld [60] cite evidence from a variety of studies suggestingthat the relationship between alcoholism and job performance deterioration is notthe simple linear one that is claimed by E.A.P. advocates. (A) While alcoholics asa group tend to demonstrate job performance impairment on indices such asabsenteeism and accident rates when compared to controls, there is evidence thatit is a special sub-group of alcoholics that is responsible for the deviation from thenorm [10, 44]. In one of those studies [10], the majority of alcoholics were foundto have lower than average accident rates in the year preceding referral. (B) In alongitudinal study of E.A.P. referrals to treatment [60], few statistically signific-ant negative correlations could be found between supervisory ratings of job per-formance and a measure of alcoholic involvement. Indeed, for some organizationsin some years, significant positive correlations were obtained. (C) There is somedoubt that deteriorating job performance is in most cases an early sign of alcohol-ism. In the above-mentioned study, for example, most E.A.P. referrals were

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found to have had a considerable history of problem drinking and could not bedistinguished from unemployed chronic alcoholic in-patients in terms of age ordegree of alcoholic involvement. Moreover, in 4 of the 5 organizations studied,little support could be found for a trend towards earlier identification over time.

Practical difBculties in E.A.P. ImplementationLimitations in applicabilityE.A.Ps appear to have been most successfully implemented in large (over 1,000employees), bureaucratically run organizations. They have been less frequentlyimplemented in medium-sized organizations and are difficult to apply to thesmall work setting (particularly if nonunionized) or to certain employee groups(e.g. executives and professionals) within larger organizations. Moreover, amongcompanies that have functioning E.A.Ps, referral rates would appear to run wellbelow estimates of alcoholism prevalence within the workforce. Typically, referralstend to be relatively high in the early period ofthe E.A.P. operation (when it iseasy to identify the most troublesome and chronic problem drinkers), but declineonce the back-log of problem employees has been cleared up (cf. [25]). E.A.P.advocates typically attribute low referral rates to a lack of support from top man-agement or union personnel, to the failure to develop clearly specified lines ofresponsibility for implementing E.A.P. policy, or to the failure to adequately trainand monitor supervisors in the identification and referral ofthe alcoholic problememployee. It is arguable, however, that the problems of E.A.P. implementationmay run much deeper - that in many cases the E.A.P. model is simply not com-patible with the objectives and structures of employing organizations. To somedegree industry might even be viewed as a reluctant customer for E.A.Ps. Pres-sures have been exerted on industry from a number of sources to find alternativesto dismissal or strong disciplinary measures for coping with the troublesomealcoholic employee. For example, reviews of labour arbitration rulings in theUnited States and Canada [2, 61] have documented an increasing trend for arbit-rators to rule in favour of the employee who was discharged for alcohol-relatedoffences when the company did not have an E.A.P. policy in effect. N.C.A. hascapitalized on that trend and has made it a strong selling point for the adoptionof E.A.Ps by industry.

Difficulties related to supervisory complianceOne of the most troublesome components in E.A.P. implementation wouldappear to be the heavy reliance on first-line supervisors to do the 'dirty work' ofconfrontation and documentation of unsatisfactory job performance. In some set-tings those difficulties are compounded by the fact that the supervisor has beenpromoted to his position from the ranks and continues to identify more with theneeds and interests of his subordinates (with whom he continues to socialize) thatwith the interests of management. He may himself be a heavy drinker and onoccasion experience some alcohol-related difficulties and, if so, will be under-standably reluctant to point his finger at alcohol-abusing subordinates.

Modem versions of E.A.Ps stress the importance of using job performance

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criteria as the primary means for identifying the alcoholic. The supervisor is fre-quently admonished in the E.A.P. literature to rely solely on signs of deteriorat-ing job performance in the identification process and to avoid playing the role ofdiagnostician. Indicators of declining job performance that supervisors areinstructed to take note of include (A) high absenteeism (e.g., excessive sick days,unauthorized absences, suspicious pattern of absences, improbable excuses formissed time), (B) on-the-job absenteeism or tardiness (late for work, absentfrom post, long lunch hours, frequent trips to washroom), (C) intoxication ordrinking on the job, (D) high incidence of accidents (both on and off the job,accidents of a suspicious nature, accidents due to carelessness), (E) decliningproductivity or quality of work (e.g. missed deadlines, declining sales, complaintsfrom customers, erratic production, excessive scrap or wastage, excessive over-time), and (F) poor working relationships (e.g. complaints from co-workers,argumentativeness, insubordination, sensitivity to criticism, excessive talkingwith co-workers). However, in studies of referral documentation supplied byorganizations with active E.A.Ps [60, 65], job performance deterioration wasmentioned as the sole indicator of alcoholism in only a small minority ofcases. Ofthe job performance indicators described above, excessive absenteeism and into-xication or drinking on the job were the most frequent reasons given for mandat-ory referrals. While some mention was often made of 'unsatisfactory job perfor-mance', the documentation of poor job performance rarely went beyond indirectindicators such as absenteeism and, when it did, was most frequently directlyassociated with intoxication on the job.

The limited range of behaviours utilized by supervisors in documentingunsatisfactory job performance appears to be due to a number of factors, includ-ing (A) the failure to develop adequate standards for making judgements aboutacceptable job performance, (B) the nature of some jobs for which objective per-formance criteria are not easily definable, (C) organizational constraints on thekinds of evidence that can be used in documenting unsatisfactory performance orthe amount of documentation required, (D) the lack of opportunity to observerelevant job behaviours (due, for example, to the large spans of supervisory con-trol in some organizations), and (E) the inability or unwillingness of supervisorsto observe or document relevant job behaviours (due, for example, to a lack oftraining in supervisory skills, pressures from unions, lack of managerial support,social pressures from subordinates). Even among those indicators that are mostreadily observable (e.g. absenteeism, intoxication, drinking on the job, acci-dents), documentation is often extremely difficult except in the most extremecases - due, for example, to their low frequency of occurrence (e.g. accidents,drinking on the job), or to problems in their detectability (e.g. absenteeism,drinking on the job) or both.

New directions in occupational alcoholism programmingIntegration of alcoholism services with effective systems of performance managementMost E.A.P. applications provide the supervisor with a manual and a brief(typically 2 to 3 hour) training programme aimed at increasing his awareness ofalcoholism problen>s in the workplace and at familiarizing him with E.A.P.

BJ.A —• D

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policies and the mechanics of documentation and referral. Most E.A.P. supervis-ory training programmes, however, are very simplistic in nature and fail to dealwith the day-to-day realities of supervising the alcoholic employee. Typically theE.A.P. is presented as an isolated piece of programming that is divorced from thebroader context of effective employee performance management.. Rarely is thereany supervisory follow-up after training to monitor the implementation of E.A.P.policies. A number of E.A.P. workers have emphasized the importance of'beefingup' supervisory training programmes. Solutions suggested have included (A) thedevelopment of problem behaviour checklists as guidelines for supervisors inidentifying the problem employee [41], (B) the use of role-playing techniques orother procedures aimed at reducing supervisors' anxieties around confrontation[9, 50], (C) the promotion of supportive supervisory networks and ongoing sup-ervisory forums to maintain contact with the supervisors [24], and (D) theestablishment of a central consulting service to provide the supervisor with directassistance in documentation and confrontation [41]. No studies, however, havebeen conducted on the effectiveness of these various procedures.

Effective supervisory practice is, of course, a highly complex activity thatdemands a broad range of interpersonal and problem-solving skills. The detectionand management of the problematic alcoholic employee accounts for only oneaspect of employee performance control. Whatever procedures are implementedfor managing the problem-drinking employee, care should be taken to ensure thatthey are developed as an integral component of the overall organizationalperformance control system and that they are presented to supervisors within thebroad context of effective employee supervision. While a number of studies can befound in the management literature on the application of training programmesaimed at increasing supervisory effectiveness [12, 22, 31, 32, 63], there has beenlittle evidence that such training programmes result in long-term changes in sup-ervisory behaviours. One exception, however, is a study by Latham and Saari [32],who tested a behavioural modelling training programme to teach supervisorsmore effective skills in dealing with employees in a variety of supervisor-employeesituations (e.g. motivating poor performers, correcting poor working habits,reducing absenteeism, handling complaints, overcoming resistance to change).They were able to demonstrate improved performance among supervisorytrainees (compared to controls) on behavioural simulations three months aftertraining and on job performance ratings one year later. Their training package,which appears to be exceptional in its design and implementation, could easily bemodified to include procedures for the management of the problem-drinkingemployee.

As discussed earlier, the major limiting factor in performance-basedalcoholism programmes concerns difficulties in the monitoring of jobperformance. Frequently monitoring difficulties can be attributed more to thefailure to develop relevant criteria for evaluating performance than to limitationsin supervisors' capabilities for making accurate observations. The lack of relevantperformance criteria has made it possible to identify only the most extreme casesand has sometimes led to the over-reliance on indirect indicators of performanceand to the application of arbitrary performance standards. A prerequisite step tothe introduction of supervisory training programmes, then, might be the over-

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hauling of the organization's performance monitoring system e.g., theclarification or redefinition of job roles, the development of objective jobperformance standards, modifications in the nature and frequency of formalperformance reviews, and the implementation of better record-keeping systems. Areview of the performance-appraisal literature suggests that the development ofvalid job performance indices is no easy task. By far the most widely used meansof gathering performance information is the use of supervisory ratings. Moststudies, however, have found that supervisory ratings bear little relationship tomore objective indices of performance. In regression studies, for example, objec-tive indices have been found to account for only 7% to 25% of the variance insupervisory ratings [13, 28]. There have been a number of attempts to derive'behaviourally anchored' rating scales (B.A.R.S.) that are designed to yieldratings of greater relevance that are expressed in behavioural terms. Althoughsuch procedures have yielded more carefully developed scales with better-defineddimensions than are found in the traditional Likert rating scales, researchfindings have been disappointing. In a review of B.A.R.S. research, Schwab,Heneman and De Cotiis [58] concluded that there is little reason to believe thatB.A.R.S. are superior to alternative evaluation instruments in reducing subjec-tivity. Subsequent studies (e.g. 13, 16, 29, 30) have tended to confirm this view,it should be noted, however, that the failure to find strong relationships betweensupervisory B.A.R.S. and objective performance indices may have as much to dowith the failure to obtain relevant objective indices as it does with inadequacies inthe B.A.R.S.

Early intervention programmesMuch lip-service has been paid to the potential of E.A.Ps as a form of earlyintervention, but there is little evidence to support that contention. Ironically,with their emphasis on the disease model of alcoholism and abstinence-orientedtreatments, E.A.Ps may in actuality discourage early identification because ofthe understandable reluctance of both the problem employee and E.A.P.personnel to apply the label of 'alcoholic' to early-stage problem drinkers. Whilethe concept of 'controlled drinking' continues to be a highly controversial andemotionally charged issue within the alcoholism treatment field, E.A.Ps mustaddress themselves more directly to the needs and problems of the heavy drinkerif they are to play a significant role in secondary prevention. The distinctionbetween 'problem drinker' and 'alcoholic' is not one which can easily be drawn(cf. [36]), but more recent diagnostic classifications, such as that proposed by theWorld Health Organization [18], tend to view alcohol abuse problems as lyingalong a continuum of severity. Some progress, moreover, has been made in thedevelopment of criteria for determining the appropriateness of moderation as atreatment goal [36] and the findings of a growing number of studies suggest thatmoderation-oriented treatments may be preferable to abstinence-orientedapproaches for the less severe problem drinker [37].

The potential for effective early intervention within the workplace and theform that such interventions might take are as yet conjectural. To date, sec-ondary prevention programmes have been most commonly targetted at convicted

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impaired drivers. The format of these programmes has usually been educationaland the focus has been largely on increasing the drivers' awareness of thehazards associated with alcohol intoxication and long-term abuse. While somereports have claimed reductions in recidivism rates as a result of programmeparticipation, findings have been less than consistent, and the results of con-trolled studies suggest little effect beyond that which can be attributed to the lawenforcement process [1]. There is little reason to believe that traditionaleducational formats would fare much better within industrial settings. However,a convergence of findings from several areas of alcoholism research are suggestiveof new directions that occupational programmes might take. These include (A)significant advances in capabilities for the early identification of high-riskdrinking populations, (B) the emergence of evidence concerning the dysfunctionaleffects of alcohol on heavy social drinkers, and (C) the promising findings ofminimal intervention approaches to the treatment of the problem drinker.

The search for early, objective biophysical and psychosocial indicators ofalcohol abuse has attracted the attention of researchers for a number of years. Bythemselves, these indices have very limited utility as 'markers' of alcohol abuse.However, composite indices of biomedical and psychosocial items show greatpromise [62]. If that promise is fulfilled, the implications for industry could bequite profound - both in terms of the potential for identifying target populationsfor early intervention and for screening individuals for occupations in whichheavy drinking practices could place their safety or that of others at great risk.

To date, much alcoholism research has concentrated on the adverse effects ofacute intoxication and chronic abuse; much less attention has been paid to theeffects of normal (typical) social drinking practices. Recently, however, evidencehas begun to emerge of measurable cognitive dysfunctioning among even rela-tively moderate social drinkers [42, 43] and there is some suggestive evidencefrom animal findings that recovery from the effects of acute alcohol intoxicationmay be much more protracted than it was previously considered to be [6, 7].There is, moreover, the suspicion that reduced productivity and accidents arisingfrom hang-overs or drinking on-the-job might be attributable to a relatively largeproportion of the workforce within some organizations [33]. Noting that the rela-tionship between industrial accidents and alcohol consumption has probablybeen grossly underestimated, Shain [59] has suggested that the merging ofE.A.Ps with health and safety programmes may present a logical starting pointin the development of earlier interventions.

Interest in the development of minimal interventions for problem drinkerswas sparked by a widely-cited study carried out by Edwards and his colleagues[19], who found that a single session of 'advice-giving' was as effective withalcoholics as a 'traditional' in-patient alcoholism programme. Miller and Hester[37] have since reviewed a number of other studies which tend to confirm thatminimal interventions can be as effective as more intensive treatments, andparticularly so for the earlier-stage problem drinkers, for whom minimal out-patient interventions appear more effective than intensive in-patient treatments.Perhaps of greatest relevance for industrial applications is the development ofbrief behavioural self-control training programmes designed to teach theproblem-drinker skills for moderating his consumption and for developing

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alternative ways of coping with problems related to his drinking [34, 35, 54, 55,56]. The fact that these programmes are readily adaptable to self-help(bibliotherapeutic) approaches [35, 38] makes them even more attractive in termsof cost-effectiveness.

It remains possible, indeed likely, that within the context of E.A.P. as itcurrently exists, there will be an increasing emphasis on the generation of self orvoluntary referrals. In fact, it was through the vehicle of self-referral that thepromise of early identification was expected by many to be achieved [60].Although these expectations may have been premature, developments in prog-ramming components which serve this end more effectively can be anticipated,particularly with the proliferation of service delivery models that encourage directaccess to third-party assessment and referral agencies [46]. The suggestions inthis paper, then, should be seen in the context of a general effort to upgrade theeffectiveness of service delivery to problem and excessive drinkers both by theextension of existing programmes and by the introduction of non-E.A.P. basedinterventions as outlined here.

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