Occupational Stress Part 2
An interview with Dr. Lennart Levi
PJR: I find it intriguing that your interest in occupational stress was triggered during your compulsory service in the Swedish Army, when a young fellow conscript developed suicidal behavior and other symptoms suggestive of PTSD because he could not cope with the sudden stress of military discipline to which he was totally unaccustomed. This is reminiscent of Alvin Toffler’s assertion that a major source of psychosocial stress was subjecting people to too much change in too short a time. It is unfortunate that greater attention was not paid to your observation, since PTSD has become a very costly health disaster due to an inability to objectively confirm the diagnosis and treatment with drugs that are not only ineffective, but also worsen the quality of life and contribute to suicidal behaviors. As emphasized in recent Newsletters, this is what happens when disorders become political footballs and their diagnosis and treatment are dictated by powerful drug companies rather than solid scientific evidence. The current emphasis on statin therapy for coronary heart disease is another example in my opinion.
In 1978 you were able to inspire your country’s Parliament to overrule the Government’s decision to defer creating a Chair for Psychosocial Medicine. You similarly succeeded in inspiring partners in the labor market to convince your Government to create a small but autonomous National Institute for Psychosocial Factors and Health in 1980 And you successfully galvanized these groups again when you were to retire from your Chair in 1995 and the Karolinska Institute proposed changing its content from “psychosocial medicine” to “molecular biology”. That points to a political career. It is therefore quite fitting that you were elected to the Swedish Parliament in 2006 as a member of the Centre Party, which describes itself as “a green social liberal party”. Although you did “retire” from your Karolinska leadership posts in 1995, and from Parliament in 2010, you still serve as an active senior adviser to the Stress Research Institute as well as to your party.
We have both been blessed with wives that tolerated our professional activities, even though they often prevented spending time with them, and Inger has actively contributed to some of your projects. They were also concerned that our excessive work activities might have adverse health effects and that we needed to take time out to relax. On one of your visits, my late wife, Marguerite, explained that she was able to accomplish this as well as spending
more time together by playing golf. Inger, who was also an ardent golfer, thought this might be a good idea, and I recall presenting you with one of my favorite golf clubs, but not sure if this helped.
I also recall meeting you for the first time when Stewart Wolf brought you to our home, and have equally pleasant memories of the time we were able to spend together at conferences in Switzerland, Russia and Hawaii. I particularly remember the surprise birthday party our mutual friend Konstantin Sudakov arranged for me in Moscow, and I will be interviewing Konstantin in a future Newsletter. Most of all, I am grateful for your warm friendship over the years and your strong support of the American Institute of Stress. I look forward to your continued cooperation and advice as we transition over to new leadership that will greatly expand our ability to provide accurate and up to date information on all stress related issues. Starting from our earliest days, we have served as an ombudsman in this domain by identifying those stress related services and products that are authentic and promising, as opposed to others promoted by charlatans and misguided zealots. This has become even more important in recent years because of the skyrocketing increased interest in stress that has generated a flood of misinformation that can be confusing to consumers as well as health professionals. Our goal is to separate the wheat from the chaff and your achievements have been of inestimable value in helping us accomplish this.
LL: I have never been an admirer of Karl Marx, but I do like one of his formulations: “All that philosophers have done is interpret the world in different ways. It is our job to change it.” Or, rather, to try to improve it. To make it happen. This, of course, turned out to be very, very difficult – but not entirely impossible. With regard to the stress field, my priority has always been to try to adjust the “shoe” (living and working conditions) to the “foot” (the human being), and not just the other way round. And, yes, you kindly donated one of your best golf clubs to me, and, indeed, I got a Green Card and started playing. But I soon found out the truth in British playwright Noel Coward’s claim that “work is much more fun than fun”.
As Selye said, “I cannot and should not be cured of my stress, but merely taught to enjoy it.” Our wives obviously recognized this, as well as other factors that promote a happy and fulfilling life. When Sigmund Freud was asked what were the ingredients of a good and successful life, his answer was “lieben und arbeiten” (to love and to work) – to love others and work for a common good. Both of us have done this to the best of our abilities. And, of course, if you love your work, as we do, that is an added bonus. In that regard, I look forward to being of assistance as the American Institute of Stress transitions over to new leadership that will expand its services while preserving the high standards and reputation for accuracy it has deservedly achieved for well over three decades.
PJR: There is much more that could be said about Lennart Levi’s other achievements and the more than 4,000 lectures and seminars he has delivered all around the world dealing with problems and solutions in Occupational, Public and Mental Health. He has been able to explain these complex issues in an easy to understand fashion in accord with Albert Einstein’s advice that “Everything should be made as simple as possible, but not simpler.” I would like to share some of these with you. As he noted with regard to stress “My priority has always been to try to adjust the “shoe” (living and working conditions) to the “foot” (the human being), and not just the other way round.”
He illustrated this with the following diagram:
To make things fit, one either has to change or cut the shoe, or remove part of the foot. Similarly, jobs often have characteristics that may not fit everyone. Rather than strictly confining and crushing workers, it may be preferable to revise the degree of their responsibility and/or the demands of their assignment to give them more control. This also applies to those with talents they have not been able to fully utilize.
Most physicians readily acknowledge the important role stress can play in the etiology and pathogenesis of numerous disorders, but would have difficulty in providing a definition of stress that everyone would accept. The term stress, as it is currently used, was coined by Hans Selye, who struggled with this problem his entire life without finding a solution. His initial description of this nonspecific response to any demand for change that he called “biologic stress” was published as a 74-line letter to the editor of Nature in 1936 entitled “A Syndrome Produced by Diverse Nocuous Agents”. But the editor insisted that the word “stress” had to be deleted since it was commonly used to mean nervous strain. As a result, the word stress never appeared and “Alarm Reaction” was substituted to describe this response, which he viewed as a coordinated mobilization of the body’s defense mechanisms. Selye was also not aware that stress had been used for centuries in physics to describe an external force that caused deformation or strain. As expressed in Hooke’s Law of 1658, the magnitude of an external force, or stress, produces a proportional amount of deformation, or strain, in a malleable metal. He often complained that had he known about this, he would have gone down in history as the father of the “strain” concept, and he had to coin a new word, “stressor” to distinguish cause from effect. Selye later defined stress as “the rate of wear and tear on the organism”, a good description of biological aging, but not very useful for scientists. And, towards the end of his life, when asked what he meant by stress his response was “Everyone knows what stress is – but nobody really knows.”
So exactly what do we mean when we refer to excessive job stress? Lord Kelvin, the 19th century mathematician-physicist who developed the absolute or Kelvin temperature scale wrote, “To measure is to know”, and “If you cannot measure it, you cannot improve it.” But if you can’t define something, how can you possibly measure it?
Numerous questionnaires have been developed to measure the severity of job stress based on environmental hazards, conflicts with
customers and coworkers, discrimination based on gender, race, religion, age, etc., but there is no clear correlation with adverse health consequences. We are frequently asked to provide lists of the ten most and ten least stressful jobs but most of these are of little value since they are based on self-report from non-representative samples. In some instances, they are instigated by unions or organizations to obtain higher wages or better benefits for their members. The link between job stress and heart attacks is so well acknowledged, that in New York and other municipalities, any policeman who suffers a heart attack is automatically assumed to have a work related injury and is compensated accordingly, even if it occurs on vacation while gambling in Las Vegas or fly fishing in a placid lake. And the dangers of being a police officer in a crime ridden and violent inner city ghetto is a lot different than those of one in a rural Wyoming village. Some people are attracted to police work because of the excitement and thrill of possible danger, and if you ask them what is the most stressful aspect of their job, it is apt to be “all the paper work.” As Lennart has emphasized, job stress is entirely based on the person/environment fit. Some Type A’s thrive in the pressure cooker of life in the fast lane, with constant time urgency, constantly multitasking and having numerous responsibilities – provided they feel in control. They would be severely stressed by a dull and dead end job that consisted solely of transferring something from one conveyer belt to another, over which they had no control. However, this might be perfect for someone who shuns responsibility, simply seeks a job that is well within his or her capabilities, poses no challenges, and can completely forget work as soon as their shift is over. Social support is also a powerful stress buster.
The best method of measuring stress and demonstrating its link to cardiovascular and other diseases is the Karasek and Theorell demand /control/ support model. Siegrist’s effort/reward approach has also been successful in predicting future illness. While these are too complex to discuss into detail here, they can be succinctly illustrated as follows:
As to advice on how to reduce stress by “fitting the job to the worker”, there is no simple formula that applies to everyone, since we all have different needs, goals and personalities. And employers can’t keep changing job descriptions and duties to accommodate these and continue to operate efficiently. But what they can do is to recognize the ingredients of a good job and to determine if any of these can be incorporated to improve the quality of life and job satisfaction. Such efforts are apt to be cost effective since they also increase productivity and profitability. Lennart uses the following slide to explain what some of these major components include:
A GOOD JOB PROVIDES:
Purpose and direction;
Regular daily activity;
Identity and self-respect;
Companions and friends;
Material benefits, salary.
(cf Marie Jahoda)
To celebrate his 60th birthday, Lennart’s colleagues and students prepared a book containing selected articles from his four decades of research. These illustrated his wide range of interests and discoveries, and his knowledge of endocrine, biochemical and physiological responses to stress that confirmed his clinical observations on gender differences and the stress of long-term unemployment. I still have my graciously inscribed dog-eared copy that also shows the stunning sideburns he was sporting at the time as seen below.
Of course, that was well over two decades ago, and he has now published over 300 papers, book chapters and books and is still going strong. I mention this since we are contemplating reviving our International Congress on Stress in 2014. This will have a focus on job stress and we look forward to Lennart Chairing this segment and bringing us up to date on the latest advances in this area.