The psychology of bullying at work: Explaining the detrimental effects on victims S. EINARSEN, E.G. MIKKELSEN & S.B. MATTHIESEN Department of Psychosocial Science, University of Bergen, Norway Introduction Exposure to bullying at work has been classified as a significant source of social stress at work (Zapf, 1999) and as a more crippling and devastating problem for employees than all other work-related stress put together (Wilson, 1991). Others have claimed work harassment to be a major cause of suicide (Leymann, 1992). Clinical observations have shown effects of exposure to workplace bullying such as social isolation and maladjustment, psychosomatic illnesses, depressions, compulsions, helplessness, anger, anxiety and despair (Leymann, 1990). Al- though single acts of aggression and harassment occur fairly often in everyday interaction at work, they seem to be associated with severe health problems in the target when occurring on a regular basis (Einarsen & Raknes, 1997). To be a victim of intentional and systematic psychological harm by another person, be it real or perceived, seems to produce severe emotional reactions such as fear, anxiety, helplessness, depression and shock (Janoff- Bulman, 1992). Victimisation due to workplace bullying appears to change employees' perceptions of their work- environ- ment and life in general into one involving threat, danger, insecurity and self-questioning (Mikkelsen & Einarsen, 2002a). According to a number of studies (see Einarsen 2000; Einarsen & Mikkelsen 2003 for a review), this may lead to pervasive emotional, psychosomatic and psychiatric problems in victims. The aim of this paper is to pre- sent research conducted by the Bergen Bullying Group on the health effects of bullying, and secondly to propose two theoretical models that might help explain the observed relationships between exposure to bullying and vic- tims' health problems. Consequences of workplace bullying Several studies based on interviews with victims have stressed the serious negative impact bullying may have on both health and well being. Although negative effects of bullying and harassment at work may also be observed on an organisational level, most of our research on effects has been on the individual victims of workplace bullying, as will be summarised below. However, in our study among Norwegian union members, 27% claimed that har- assment had influenced negatively on the productivity of their organisation (Einarsen, et al., 1994). In the study among 500 male industrial workers, a significant negative association was found between exposure to bullying and psychological health and well being (Einarsen & Raknes, 1997). Exposure to harassment explained 23% of the variance in self- reported psychological health and well being. The strongest relationship existed between experi- ences of personal derogation and psychological well being. In our study among Union members (Einarsen et al., 1996), significant relationships were found between experienced bullying and both psychological, psychosomatic and muscle-skeletal health complaints. The strongest correlation was found between bullying and psychological complaints where experienced bullying predicted 13% of the variation. A total of 6% of the variation in muscle- skeletal problems could be statistically predicted by the different measurements of exposure to bullying. These findings are very much in line with those of Zapf, Knorz & Kulla (1996) who found that mental health variables showed highly significant differences between harassed and non-harassed respondents. Zapf and associates (1995) also found that victimization in the form of personal attacks had especially strong correlation with mental health variables. In view of the particular health symptom constellation found in many studies, it has been argued that many victims of long term bullying at work may in fact suffer from post-traumatic stress disorder (Bj6rkqvist, et al., 1994). The diagnosis PTSD refers to a constellation of stress symptoms following a traumatic event, where the trauma first of all is relived through returning, insistent and painful memories of the event, recurring nightmares, or by intense psychological discomfort to reminders. Secondly, the patient avoids situations associated with the trauma, which may include memory problems of the actual event. Thirdly, the patient may lack the ability to react emotionally adequate, for instance by having reduced interests in activities that used to bring joy, by showing limited affect or by the feeling of having no future. Patients with PTSD are also hypersensitive, be it with sleeping problems, diffi- culties in concentration, by being highly tense and irritable and with bursts of fury, by having exaggerated reac- tions to unexpected stimuli or by reacting with physical symptoms to reminders of the actual traumatic situations In a study among 102 victims of long term bullying at work recruited among members of two Norwegian national associations against bullying, Einarsen, Matthiesen & Mikkelsen (1999) discovered that 75% of victims portrayed stress symptoms indicating a post-traumatic stress disorder. Even 5 years after the bullying has ceased, as many as 65% reported symptoms indicating PTSD. A total of 76,5 percent scored above a level on the Hopkins Symptoms CheckList indicating psychiatric pathology as opposed to 21,4 percent for females and 12,4% for males in a con- trol group. The level of post-traumatic symptoms were highly related to the intensity of the reported aggressive behaviors, and were especially salient if the aggressive behavior where perceived as being of a personally degrad- 1 ing nature. Similar results where found in a group of 118 former Danish victims of workplace bullying (Mikkelsen & Einarsen,2001). The role of personality A new study of personality and personality disorders among Norwegian victims of bullying at work using a comprehensive measure of personality called the MMPI-2 revealed some interesting insights into the issue of victim personality in relation to exposure to bullying and its traumatizing effects (Matthiesen & Einarsen , 2001). A total of 85 individuals who had been exposed to bullying at work, recruited among members of two Norwe- gian associations of bullying victims, participated in the study. The study demonstrated that victims of bullying at work portrayed a personality profile indicating a tendency to emotional and psychological disturbance on a wide range of personality factors. A so-called 3-2-1 profile on the MMPI-2 was found, indicating a personality with serious psychosomatic problems resulting from stress and anxiety and a tendency to convert psychological stress into physical symptoms. Persons with this configuration employ defense reactions such as displacement and denial on a large scale, and may have problems with more finely graded psychological explanatory mecha- nisms to their problems (see Matthiesen & Einarsen, 2001 for more information). However, the study showed that victims of bullying were not a homogeneous group. One group of vic- tims portrayed a profile indicating an extreme range of severe psychological problems and personality distur- bances. This group, called the “seriously affected” reported a range of emotional and psychological problems al- though they reported a relatively low exposure to specific bullying behaviors, a result indicating that personality is of importance in determining how bullying is experienced and how it is reacted to. These victims appeared to be depressive, anxious, suspicious, uncertain of themselves, and troubled by confused thoughts. The second group, called the “disappointed and depressed” portrayed a tendency towards becoming de- pressed and being suspicious of the outside world. It is not surprising that a person may become extremely skep- tical and suspicious of other people after having been subjected to sustained bullying. The third group, called the “common group”, portrayed a quite normal personality, in spite of having experienced the largest number of specific bullying behaviors. Such results may indicate that a specific vulnerability/hardiness factor may exist among some both not all victims of bullying at work. Persons who are already suffer from psychological prob- lems are probably more likely to suffer long-term psychological and physical problems in the wake of bullying and serious personal conflicts. Persons with psychological problems, low self-confidence and a high degree of anxiety in social situations may also be more likely than others to feel bullied and harassed, and they may find it more difficult to defend themselves if they are exposed to the aggression of other people. However, a caution must be put forward. There is every reason to believe that it is the “seriously affected” group that is most likely to contact health personnel such as psychologists and psychiatrists, as well as adopt judicial means of obtaining restitution. Hence, based on these results we must warn both psychologist and psychiatrist and other profession- als to generalize observations of the personality of victims of bullying purely on the basis of clinical experience. Explaining a PTSD reaction: a cognitive framework Intuitively, it may seem strange that people develop symptoms of PTSD when exposed to interpersonal aggression that is typically indirect, rather subtle and often verbal in nature. However, it may not be the external event itself that causes the trauma, but rather the potential effect this event may have on the inner world of the tar- get. According to Janoff- Bulman (1989; 1992) events are traumatic to the extent that they threaten to shatter our most basic cognitive schemas. These core schemas involve fundamental beliefs that the world is benevolent and meaningful, and that we, as individuals, are worthy, decent and capable human beings deserving other people's af- fection and support (Janoff- Bulman, 1989). Providing us with expectations concerning ourselves, other people and the world in which we live, these basic schemas or assumptions enable us to operate effectively in our daily lives. Moreover, being fundamentally positive, the assumptions endow us with a sense of invulnerability central to human existence. When exposed to highly distressing events, suddenly and painfully victims become conscious of the fragility of those basic assumptions on which their lives are founded (Janoff-Bulman & Frieze, 1983). In so far as we need stability in our conceptual system (Epstein, 1985), such abrnpt changes in core schemas are deeply threatening and may result in an intense psychological crisis (Janoff-Bulman, 1992). The conceptual incongruity between the trauma-related information and prior schemas leads to cognitive disintegration (Epstein, 1985; Janoff-Bulman, 1989), which in turn gives rise to stress responses requiring reappraisal and revision of the basic schemas. Hence, victims must rebuild new and more viable core schemas, which account for the experience of being victimised (Janoff-Bulman & Schwartzberg, 1990). However, some victims have difficulty doing so. Instead of resolving the cognitive-emotional crisis forced upon them by the traumatic event they remain in a chronic state of cognitive con- fusion and anxiety that is characteristic of PTSD. This hypothesis was tested empirically by Mikkelsen and Einarsen (2002a) in a group of 118 Danish victims of bullying and a matched non-bullied control group- The results yielded significant group differences on six out of eight basic assumptions. Victims of bullying considered themselves to be less worthy, less capable and unluck- ier than did the control group. In addition, they perceived the world as less benevolent, other people as less suppor- tive and caring, and the world as less controllable and just. The difference between victims and non-victims were particularly noticeable on the latter assumption. 2 At least one possible explanation may be forwarded as to why the victims portray these assumptions about the world: Many victims consider themselves as competent and resourceful employees (Zapf, 1999a). If victims have had a successful professional career prior to exposure to bullying, then they may with good reason fail to comprehend why they of all people have become targets of repeated allegations of being stupid, useless or ineffec- tive. However, it may also be the case that the victims who participated in our study (Mikkelsen & Einarsen, 2002a) tended to have negative views of themselves and the world prior to their victimisation. Indeed, such nega- tive views characterise individuals high in negative affectivity (Watson & Clark, 1984). Although individuals high in negative affectivity are prone to experiencing and reporting high levels of stress (Watson & Clark, 1984) the question remains as to whether this personality tl-ait alone can account for the severity of victims' symptoms. If victims' schemas were negative in the first place, exposure to bullying would come as no shock but rather confirm the validity of their schemas. Based on our own personal experience of working with victims of bullying, we have come to believe that some victims may have had umealistically positive, in some cases even naive assumptions prior to their victimisation. In a similar manner, Brodsky (1976) claims that some victims appear to have an unre- alistic view of their own abilities and resources and of the demands of their work situation and their tasks. Hence, for these victims exposure to bullying may be extremely traumatic. In case they are unable to rebuild or adjust the assumptions that have previously provided them with a basic feeling of invulnerability, victims of bullying may remain in a constant state of anxiety. In the long run this may then lead to a breakdown in a range of basic physio- logical processes. A socio-biological perspective Although the term bullying appears to connote open and direct aggressive behaviours, many victims of bully- ing are also subjected to covert behaviours. For instance, many victims report that they are "treated like air" or that they suffer the "silent treatment". Indeed, the systematic exclusion and rejection from social groups, i.e. social os- tracism (Williams, 1997), appears to be a common feature of bullying. Exposure to social ostracism signals that the target is in danger of being excluded from an important group, in this case the work group. From an evolution- ary perspective there is probably a very basic fear in all human beings of being excluded from and receiving the at- tention of important significant others. Indeed, as a social and tribal primate, the survival of human beings depends on them being integrated in a well-functioning social group. Accordingly, from an existential point of view, social exclusion may be perceived as life threatening. At the very least, it symbolises to the target what death is. Indeed, many victims describe exposure to bullying as "psychological drowning" (Einarsen, Matthiesen & Mikkelsen, 1999). Therefore, it is no wonder that exposure to social ostracism is associated with extreme anxiety and a break- down in basic physiological process. According to biologists and physiologists, exposure to ostracism leads to a general physiological deregulation by interfering with the immune system and brain functions relating to aggres- sion and depression (Williams, 1997). The ambiguous nature of ostracism combined with its potential extreme consequence results in a situation where even vague perceptions of being ostracised may have strong effects on the targets. According to Williams (1997), perceptions of being excluded or rejected from a relationships threaten four basic social needs: I) It deprives people of a sense of belonging to others. 2) It threaten victims' self esteem by indicating that they are unworthy of love and affection 3) It deprives the target's need to control interactions with others and its desired outcomes 4) Consequently, exposure to ostracism threatens peoples' need for a meaning; reminding them about their fragile and temporary existence. Thus, social ostracism may be experienced as a kind of social death (Williams, 1997). In a short term perspective, and depending on which need threatened as well as individual differences in the salience of different needs, a breach in the fulfilling of these four basic needs causes pain, anxiety and worry. In the long run, the frustration of these needs may lead to extreme anxiety, depression and even psychotic reactions. Hence, this theoretical frame- work might account for the desperate, erratic and sometimes highly aggressive behaviours displayed by victims of indirect and subtle forms of bullying (Einarsen et al., 1994). Interviews with victims typically show how social os- tracism gradually reduces the victim's ability to cope with the demands of daily living. This may again lead to a situation where the victim displays more and more atypical and abnormal behaviours. Such behaviours may in turn reinforce other people's negative attitude towards the victim leading to further victimisation. Consequently, the victim's self-esteem and self-confidence may suffer considerably. Combined with the anxiety caused by the ostra- cism, this might result in him or her developing severe psychological and psychosomatic problems. Conclusion Previous research clearly indicates that there is a relationship between exposure to bullying and symptoms of low- ered well-being and psychological and somatic health problems on the other. Furthermore, victims themselves are generally convinced that their health problems are linked to their exposure to bullying. Hence, a causal link be- tween exposure to bullying and strain reactions appears plausible, this despite a scarcity of methodological sound 3 evidence. While research suggests that the symptoms portrayed by many victims of long-term bullying are identi- cal to those outlined in the PTSD diagnosis, more empirical and theoretical work needs to be conducted on what makes bullying at work such a potentially traumatic event. However, it is important to note that in order to be di- agnosed with PTSD, victims must have experienced or witnessed a traumatic event that involved actual or threat- ened death or serious injury to their own or other people's physical integrity (APA, 2000). Also, they must have felt scared or terrified whilst being victimised. The former stressor criterion poses a problem in relation to bullying that are primarily non-physical. Thus, at the present point in time, most victims cannot straightforwardly be diag- nosed with PTSD (Mikkelsen & Einarsen, 2000a). Since a revision of the PTSD criterion A1 as outlined in the DSM-IV-TR (APA, 2000) may not be forthcoming, perhaps alternative diagnoses should be considered. Leymann and Gustafsson (1996) found depression and generalised Anxiety Disorder to be the most common co-morbid di- agnoses. Alternatively, Scott and Stradling (1994) have proposed a supplementary diagnosis, Prolonged Duress Stress Disorder (PDSD), which might account for the stress symptoms displayed by victims exposed to prolonged stress of relatively less intensity (see Mikkelsen & Einarsen, 2002 for a discussion of the PTSD stressor criterion). Whichever diagnosis one may eventually use, the main issue is to understand just how psychologically destructive bullying can be. Victimisation at work may not only ruin employees' mental health, but also their career, social status and thus their way of living. In order to advance our knowledge in this important field of inquiry, future re- search should generally be more theory driven than has been the case until now. In this chapter we have suggested that two such perspectives to account for the observed effects of bullying on health and well-being. The findings and theoretical explanations presented in this paper clearly have important consequences for the treatment and re- habilitation of victims of bullying. In our experience psychologists and medical doctors incorrectly diagnose many victims, providing diagnosis such as paranoia, manic depression, or character disturbance and hence treat them ac- cordingly. Victims tend to perceive such treatment as maltreatment and secondary victimisation, which further contributes to their suffering. References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders IV – Text revision. Washington DC: American Psychiatric Association. Björkqvist, K., Osterman, K., & Hjelt-Bäck, M. (1994). Aggression among university employees. Aggressive Behavior, 20 (3), 173-184. Brodsky C.M. (1976). The harassed worker. Toronto: Lexington Books, DC Heath and Company. Einarsen, S. (1999). The nature and causes of bullying at work. 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European Journal of Work and Organizational Psychology, 5, (2), 215-237. 5 The Workplace as a Setting for Health Promotion in EU Public Health Policy H. KLOPPENBURG European Comission / DG Sanco/G3 Health Strategy The new health strategy of the Community starts with the legitimate needs and expectations of our citizens. I quote "People attach great priority to their health. They expect to be protected against illness and disease. They demand that their food is safe and wholesome, and that the products and services on the market meet high safety standards. They want to bring up their children in a healthy environment and they expect their workplace to be safe and hygienic." This is our common starting point, from which we all work to achieve a coherent and effective approach to health issues, across all the different Community policy areas. At the centre of the new health strategy is a new frame- work for public health, which includes a large number of clear objectives and various policy instruments. The key initiative is the Community Action Programme on Public Health. On this programme a compromise of the European Parliament and the Council has been reached during the conciliation procedure three weeks ago. The total budget for the six years programme amounts to 312 million EURO. The implementation of the new public health pro- gramme will commence on the first of January next year. As you may know this programme focusses on three priori- ties: 1. A comprehensive health information system will be set up which will provide us with the key health data; 2. In order to improve our capability to respond to new threats to public health respective structures and systems will be established; 3. The EU will continue with the development, dissemination and implementation of effective health promotion and disease prevention measures. The policy development in public health will be supplemented by a new mechanism, the European Health Fo- rum, which will be developed as a platform for dialogue for the public health community at large. Finally, the Commis- sion is working on mainstreaming health in other Community policies. This so far has been a brief summary of the key elements of the new health strategy of the Union. Work What role does the world of work play in this context, and how can the promotion of workplace health contrib- ute to reaching the strategic public health targets? Work is a fundamental part of our life and has a significant impact on health and the quality of life. The health of our populations, our communities and families, is based on both the quality of working and non working life. The relationships between work and private life are very complex. However, we are well aware of, for example, the health- damaging impacts of unemployment or long working hours on health and social life in our communities. The Lisbon European Council has noted that Europe is going through a transition to a "knowledge-based econ- omy" which is accompanied by deep changes affecting our economies and societies. The health of our populations is determined by a host of factors, including everbody’s genetic make up, social and economic conditions and personal behaviour. Public health focuses on the underlying causes of ill health. There- fore, the world of work should be seen as a key arena for public health which is deeply connected with all other arenas of human life. The new health strategy intends to develop responses to current health trends and challenges for public health. A number of serious public health problems have to be addressed. These include among others : 1. high levels of premature death from diseases related to lifestyle (cardio-vascular diseases and cancer); 2. substantial levels of morbidity and disability from mental illness, musculo-skeletal disorders; 3. new risks to health; 4. the resurgence of major infectious diseases (like tubercolosis); 5. wide variations and inequalities in health status. With regard to these health problems, work "hosts" a wide range of factors that either damage or promote health. Scientific evidence strongly confirms what we all experience in daily life: the way how work is organised, and the level of mutual social support between colleagues influence our personal health practices, and thus determine our own health. 6 The world of work also bears enormuous challenges for our health systems. As you all know, the costs of health systems are a major charge on national budgets, and increasing health care costs are an important problem for public budgets and public policies. A recent study in Germany revealed national data on the costs of work-related diseases. According to these data presented by the Federal Institute of Occupational Safety and Health, work-related diseases accounted for 28,4 Bil. EUR in 1998. Among the three most important factors, the study identified heavy loads, span of control and the level of psychological demands. This confirms the growing importance of mental health and stress, which rightly have been identified as key issues in the new health strategy. Stress and Work Life Balance Research has shown the complex interactions between work organisation, job design, stress and a number of health consequences, particularly impacts on cardio-vascular diseases and musculo-skeletal disorders. The phenomenon of stress today shows how strongly stress at work and stress at home are related to each other. Too long working hours, for example, negatively affect family life, with unhealthy consequences for our children and their lifestyles, which in turn contributes to bigger health problems at a later stage within the life cycle. Today we speak about work life balance, which includes several issues, the conciliation of working and non- working life, the career perspectives of women, the opportunities for individual engagement in voluntary activities, and working without limits. Work life balance has become a metaphor for changing values in our society: social values are becoming more important to the younger generation, life has to be meaningful and work is only one element. Business and human resources have to respond to the changing values and expectations of a new generation of managers. From a public health perspective, a healthy balance between working and non-working life is of crucial impor- tance for health and well-being of the European citizens. Workplace Health Promotion How can public health make use of the workplace arena, in order to improve the health of the general popula- tion? Generally speaking, there are a number of public health means, preventive measures such as vaccination and screening, health education and information campaigns and finally health promotion, which involves empowering peo- ple and communities to make healthy choices to improve their health. Health promotion principles have been applied to the workplace setting with considerable success. Public and private enterprises can be seen as small communities which can significantly contribute to empowering their employees, and thus help to create a healthy work life balance, which in turn is a fundamental base for healthy families, cities and communities. Please let me briefly describe the approach the European Commission has taken in order to improve workplace health from a European perspective. In the context of the previous Public Health Action Programme a number of health promotion networks have been supported. One is the European Network for Workplace Health Promotion, which was established in 1995 and subsequently supported by the Commission. The mission of this network is to develop and promote good workplace health practice in Europe. The vision is defined as "healthy employees in healthy organisations". The European network for workplace health promotion comprises organisations such as national occupational health and safety institutes, public health institutions and Ministries of Health and Labour from all Member States of the European Community, the countries in the European Economic Area and a number of candidate countries. The network has organized 3 Europe-wide intiatives, focussing on larger enterprises, SMEs and now public administrations. For all these 3 economic sectors models of good practice have been identified all over Europe and disseminated. In addition, workplace health policies and strategies for implementation have been developed. The first step was the development of the Luxembourg Declaration in 1997 which for the first time ever de- fined workplace health promotion from a European perspective and created a common understanding between the dif- ferent European regions and across different disciplines. The main definition by the way was introduced by the repre- sentative of the Danish Institute for Occupational Safety and Health. The key issues as you see here are - the stakeholder approach (combined efforts of all stakehoders) - comprehensiveness (lifestyle + work organisation + participation). SMEs, which make up to more than 90% of companies in the EU, need a different approach. This was laid down in the Lisbon Statement on Workplace Health in SMEs. This conference now concludes the current initiative focussing on public administrations. The fourth initiative of this network, which will also be supported by the Commission, will now concentrate on improving the interface between the European and the national level, by developing informal infrastructures for work- place health promotion. These infrastructures may be established as open national fora for workplace health, with a view to initiating a national dialogue on how workplace health can be used as an arena for public health. 7 In addition, the network will develop a European WHP tool box, which is very much needed especially in countries which do not have a longer tradition in WHP. Another priority will be to analyse the economic impacts of investments in workplace health. This issue is now being discussed under the heading of the "business case". The new public health programme will, as I already mentioned, commence at the beginning of next year and it will continue with those strategies which have demonstrated success under the previous programme. However, a more coherent approach is needed, which is able to respond to the new challenges, some of which I mentioned above. The new programme will address health determinants. The main priority health problems include cancer, cardio-vascular diseases and mental illness, which can only be successfully addressed by combining lifestyle ap- proaches with action regarding major socio-economic and environmental fators. The mechanisms to help improve the effectiveness of health interventions include the provision of information, the support of innovative projects, the devel- opment of guidelines of good practice and the comparison and analysis of policies. Mainstreaming Health Mainstreaming health in other policies has been established as a priority field for DG Sanco. In this context the new Community strategy on health and safety at work "Adapting to change in work and society" developed by DG Employment can be seen as a major step forward. This new strategy adopts a global approach to well-being at work and seeks to develop a culture of risk prevention and to build partnerships between all the health and safety players. We are all well aware of the political difficulties and obstacles to establishing dialogue and even partnership between different policy sectors, which in many cases sometimes seem to have forgotton to talk to each other. In this sense, both strategies have complementary qualities, and may open up a platform for inter-disciplinary approaches both at European and national level. Public health, as well as health and safety at work, can only win in co-operation. An excellent example for this belief is the sector of small and medium sized enterprises, which covers the ma- jority of workers all over the world and in the European Union too. It is quite obvious that the traditional inspection policies of health and safety were not able, due to simple logistic constraints, to transport the health message into this highly fragmented economic sector. The solution is networking and building partnerships with so-called intermediary organisations, who are part of the mileu of smaller businesses. Public health institutions are often well placed to be part of these intermediary net- works. On the other hand, improvements in public health depend on successfully integrating health into the business agenda of SMEs given the size of this sector. Investing in Promoting Workplace Health In my presentation I tried to identify the reasons why public health should invest in promoting workplace health. In the private sector, one speaks about "a good business case" if an investment can demonstrate to contribute to the bottom line, contributes to improving productivity, sales figures, return on investment and so on. In general terms, a business case refers to the relationship between investment and its contribution to realizing the core targets of a specific setting. This is independent of the nature of the investment and of the type of target and setting. Therefore we can speak about various business cases. My argument here is that there is a good business case for public health to invest in workplace health. The core target of public health, from a European Union perspective, is a high level of health protection for our populations. This can be achieved by investing in a range of measures which help to influence the underlying factors of ill health, the health determinants. Workplace health promotion is one avenue, among several others, which should be used to reach those deter- minants which can be influenced in the setting of work which as such encompasses a wide range of specific settings. Each setting varieing according to size and economic sector has again a specific business case for investing in work- place health. Public administrations are governed by public defined targets which are different from economic targets of a private sector enterprise. Among the core targets of public health is the cost issue which I touched on earlier. If work-related diseases are among the critical factors for health costs, as shown by a national study in Germany then public health should have good arguments to try to influence this part of the cost development. According to the results of this study we know where measures should start in order to generate a substantial impact: ergonomics, work organisation and job design. Workplace health promotion which focusses on integrating health into the agenda of engineers, plant managers, change specialists, human resource managers has the best chance of reducing costs for public health. In another sense this is a concrete example of mainstreaming health in other policies or disciplines. Individual health practices (diet, stress, alcohol, exercise etc.) can only be influenced by creating environments which provide incentives for healthy changes and the right decisions. Innovation and Health Finally, I would like to draw your attention to a new and very important business case argument for promoting workplace health from a European Union economy perspective. The Union has defined a new strategic goal for the next decade: to become the most competitive and dynamic knowl- edge-based economy in the world. Innovation is the key for economic development in the European Union. 8 Innovation is the renewal and enlargement of the range of products and services and the associated markets; the establishment of new methods of production, supply and distribution; the introduction of changes in management, work organizations, and the working conditions and skills of the workforce. The recent results of the first EU innovation scoreboard showed a clear innovation deficit of the economies of the Member States relative to our main competitors Japan and the US. Especially, the SME sector plays a crucial role with regards to the innovation performance of national economies. Workplace health impacts on the quality of human resources and significantly contributes to developing an environment for innovation. We need more and better jobs based on strong social cohesion. Promoting workplace health, in the broad sense which I have outlined in my presentation, is one of the hidden success factors for modernisation and economic development. Conclusions Finally, I would like to come to some conclusions: 1. The available evidence is sufficient to guide our action. We know that lifestyle factors can be influenced, and we have striking evidence base for interventions in the area of participatory work organisation and job design. 2. Our European values and traditions clearly indicate that health is not only an individual issue. We are embedded into social contexts, our well-being is shaped by working and living conditions. Therefore: promoting workplace health is about more than advice to quit smoking. 3. Workplace health practices can only be effective if they are based on good practice criteria (see the good practice criteria of the ENWHP). 4. Our economies and European competetiveness will be entirely dependent on our ability and capacity to initiate innovation in all areas and sectors of our society. And we clearly know: there is no innovation without health. 9 Preventing Work-related Psychosocial Risks: European Perspectives CH. SEDLATSCHEK European Agency for Safety and Health at Work, Bilbao, Spain Introduction Almost a third of the entire working population in the European Union is affected by work-related psychoso- cial risks, statistically often expressed as “work-related stress”. This is a staggering statistic. In general stress is anything but beneficial – it is an insidious, disruptive and detrimental phenomenon, the cause of growing concern among the scientific and working community. Work is not the only cause of stress in our lives. But research shows that there are clear linkages and, as we are spending an increasing amount of our waking lives at work, it indicates that work plays a key part in our total stress. The prevalence of work-related stress within the EU - Europe's second biggest occupational health problem Available European figures show the scale of the problem: (cid:57) In the EU work-related stress is the second most common occupational health problem, after back pain, affecting 28% of employees in 2000 [1] or 41.2 million people - more than the entire population of Spain or the combined populations of Portugal, the Netherlands and Belgium. (cid:57) Anyone can be affected. Stress can occur in all organisations and sectors and at all levels. (cid:57) On average, higher proportions of women reported experiencing stress than men, according to a Eurostat analysis of 10 EU countries. [2] Studies have shown that work-related stress is due to a mismatch between employees and their working condi- tions, job content and how the organisation is structured. Although it can be triggered by a wide range of factors, com- mon causes include: Lack of control [3]: This has repeatedly been associated with stress and with anxiety, depression, apathy and increased incidence of cardiovascular symptoms. More crucially, lack of control remains a major issue for many workers. 35% say they have no control over the order of their tasks 29% have no influence over working methods 30% have no control over speed 39% cannot determine when they have a break 55% have no say on their working hours. Monotony: 40% of staff, on average, complain of monotonous work, with elementary workers and machine operators reporting the highest levels (57% each). In addition, 57% have to make repetitive hand and arm movements and 32% perform repetitive tasks for up to 10 minutes each time. Tight deadlines: Almost two-thirds of workers (60%) contend with tight deadlines 25% of the time, while 29% face 'the wire' either all the time or most of it. Overall, 40% said deadlines led to unhealthy levels of stress most of the time. Working at high speed: 56% of staff claim to work at high speed for at least a quarter of their time and 24% said this was a regular occurence. In 40% of cases this led to problematic levels of stress. Exposure to violence, bullying and other forms of harrassment: This is a growing concern in Europe. According to one study, 3 million employees in the EU (2% of the workforce) claim to have been subjected to sexual harassment, 6 mil- lion (4%) to physical violence and 12 million (9%) to intimidation or bullying. Violence - and the threat of violence - is becoming a major issue for employees in the frontline of public service, such as medical and transport staff. Hazardous physical working conditions: Noise is one of the commonest stress-inducing complaints although there are many others, especially in the manufacturing sector. Biological, radioactive and chemical risks are just a few. 10