Occupational Stress Part 1
An interview with Dr. Lennart Levi
Numerous surveys show that occupational stress is far and away the leading source of stress for adults and that it has progressively increased over the last four decades. There is no one more qualified to discuss the sources of this growing pandemic, as well as its adverse health and fiscal effects than my good friend Lennart Levi, MD, PhD, Emeritus Professor of Psychosocial Medicine at the world renowned Karolinska Institute in Stockholm. Lennart has been the recipient of numerous honors and accolades, including the lifetime achievement award from the American Psychological Association and NIOSH (National Institute of Occupational Safety and Health), the Royal Swedish Medal of Merit and the Hans Selye Award at our 1993 International Congress on Stress. More recently, an annual 100,000 SEK Skandia Lennart Levi Prize was established to celebrate his 80th birthday and to “reward research, education and dissemination of information to promote human health, development, productivity, creativity and/or well-being.”
Lennart has written and/or contributed to numerous books and over 300 scientific publications. He has also left a legacy of distinguished students and colleagues to carry on and extend his ground- breaking research, which led to a renaissance of interest in stress in the 1970s. We will discuss this and other aspects of his long and illustrious career, but I would like to begin this interview by inquiring about what stimulated his interest in job stress. This apparently began even before he received his medical education, and as will be seen, soon became a lifelong preoccupation.
PJR: I have often wondered if your interest in stress was kindled in medical school, since, although the two are not mutually exclusive, you had decided early on to pursue a research career in academic medicine rather than becoming a practicing physician, I also recall that when you received the Hans Selye Award at our 1993 International Congress on Stress in Switzerland, you mentioned that you had been particularly impressed by Selye’s magnum opus Stress, which was published in 1950. I suspect this was probably prior to your entering medical school, so perhaps you were interested in stress prior to that. At the time, most of the literature dealing with the health effects of emotional and psychosocial stress came from research on experimental animals. Although there were anecdotal reports, there were few scientific studies in humans. Could you tell us more about what stimulated your interest in stress, and particularly job stress, how you came to found the Laboratory/Department/Institute of Stress Research at the Karolinska Institute, and some of the individuals who influenced or assisted you in this endeavor? I believe this began in 1959 with the collaboration and support of the departments of Medicine and Psychiatry.
LL: You are right – my interest started early in life, in fact even before I entered medical school. I was inspired by two events. The first occurred during my compulsory military service in the Swedish Army. One of the other conscripts living close to me reacted intensely to the stress of military discipline to which he was totally unaccustomed. After three sleepless nights he became psychotic – and was very close to succeeding in committing suicide. It made a deep impression on me that a seemingly normal young man exposed to just a few days of unpleasant but in no way extreme military training could switch from normality to psychosis and suicidal behavior.
A few months later, I spent half a year studying psychology, before entering medical school in 1951. Soon after, I read and was deeply influenced by Hans Selye’s magnum opus “Stress”, published the year before. My subsequent studies in anatomy and physiology convinced me that the human brain was an integrated part of the human organism and in no way isolated from the rest of the human body. In 1959 when I was an intern in the Department of Internal Medicine at the Karolinska University Hospital, I prepared a small plate reading “Laboratory for Clinical Stress Research” and attached it to the door of my office. This was encouraged by two of my mentors, Dr. Henrik Lagerlöf, Professor of Internal Medicine, and Dr. Börje Cronholm, Professor of Psychiatry. Both of them regarded this initiative as the beginning of a bridge between their clinics and disciplines. Other crucially important mentors were Dr. Åke Swensson, Professor of Occupational Medicine, who encouraged me to apply experimental methods to everyday life situations, and Dr. Ulf von Euler, Professor of Physiology, who taught me about the physiological and biochemical parameters of the response to stress, and later received the 1970 Nobel Prize in Physiology or Medicine. But at the time it was virtually impossible to get any grants for stress research. And the great majority of Swedish professors at medical faculties were either indifferent or actively opposed to the stress concept and its implementation in medical practice.
It was well known that humans had responses similar to those seen in experimental animals when they were exposed to drastic stressors that bordered on torture. Much less was known about how we reacted to the far more subtle stressors encountered on a daily basis. Even less was known about the pathogenic effects of exposures typical of ordinary life, especially in the workplace. Our approach here was to combine epidemiological studies with experimental ones, by making use of changes in working conditions taking place for reasons unrelated to our research projects, or by manipulating such conditions experimentally. The latter approach necessitated close collaboration with our social partners in the labor market. Eventually, both management and labor started to see the potential importance of the entire problem area, for better or for worse. As a result, in 1975 the President of the Swedish Confederation of Professional Employees wrote an official proposal to the Swedish Government about the creation of a Chair for Psychosocial Medicine, suggesting me as its first holder. Since there was no response, he reiterated this the following year, and the Government circulated the proposal widely to appropriate authorities and organizations to solicit their comments and opinions. Because the great majority of responses were favorable, both the Swedish Medical Research Council and the Office of the Chancellor of the Swedish Universities proposed such a Chair with top priority. For reasons unknown to me, the Government refused, but the Parliament took a most unusual step by overruling the Government, which then appointed me Professor of Psychosocial Medicine in 1978. The Government noted this political manifestation across party lines and also appointed a commission to study our future place in the national organization. The Commission, with representatives from five Ministries, intended to fuse our Stress Research unit with another Institute for Environmental Health, 10 times larger than ours. Again, the Social Partners on the labor market jointly expressed their dissatisfaction and demanded a detached, autonomous organization for our activities. The Government gave in and such an authority was created in 1980, the National Institute for Psychosocial Factors and Health, with me as its first Director, and with the Stress Research Laboratory remaining as a separate unit under my leadership within the Karolinska Institute.
PJR:I recall that in 1970, you were instrumental in having the World Health Organization (WHO) and the University of Uppsala, Sweden, co-sponsor a series of five interdisciplinary, intersectoral and international symposia on “Society, Stress and Disease”, and you edited these proceedings in five major volumes, published by the Oxford University Press (1971-1987). And because of the achievements of your Stress Research group, it was designated the first World Health Organization Collaborating Centre for Research and Training in psychosocial factors and health in 1973. You continued to be a consultant not only to WHO, but also the International Labor Organization (ILO) and other United Nations (UN) specialized agencies, and served as Chairman of the Section on Occupational Psychiatry of the World Psychiatric Association from 1982 to 2005, as well as President of the International Stress Management Association. All of these activities, especially the international symposia, brought you in close contact with leading stress researchers all over the world too numerous to list. I have written about many of these mutual friends in previous Newsletters, and since they will be familiar to our readers, would appreciate it if you could comment briefly on a few such as David Hamburg, Stewart Wolf, Richard Rahe, Ulf von Euler, René Dubos and Töres Theorell, who succeeded you at Karolinska. On another note, several years ago, I had dinner with Alvin Toffler, another of our Founding Trustees, who emphasized that subjecting individuals to too much change in too short a time was a major source of stress. With respect to job stress, he indicated that he had visited you and was impressed and influenced by your views, and wondered if you recalled this meeting.
LL: As you correctly surmised, the WHO-sponsored series of five international symposia in Stockholm facilitated my collaboration with stress researchers all over the world. Hans Selye took a very active part in most of these and helped me by contacting researchers who studied stress in human as well as animal models. One of the most active participants in these symposia was Dr. David A. Hamburg, Professor of Psychiatry and Chair of the Department of Psychiatry at Stanford University in California. When he was appointed President of the Institute of Medicine, National Academy of Sciences, he asked me to write a chapter on “Psychosocial factors and health” for the U.S. Surgeon-General’s 1979 report on health promotion and disease prevention. As you know, his daughter Peggy Hamburg is now FDA Commissioner. I later took an active part in related activities of the American Sociological Association under its President Mathilda White Riley, as well as the American Psychological Association’s series of major stress conferences.
Another very influential participant of our 1970 Symposium was Stewart Wolf, a pioneer of psychosomatic medicine but also a marvelously cultured person, who chaired our session on “Experimental, clinical and epidemiological evidence concerning specific diseases provoked by psychosocial stressors”. He became a close friend and inspired many of our activities during many decades. One of the difficulties early on in our field was the need to measure “the slings and arrows of outrageous fortune”, i.e., the stressors. Here, Richard Rahe made a crucially important contribution together with Thomas Holmes. Their “Social Readjustment Rating Scale” inspired my collaborator and successor Töres Theorell, to eventually develop his and Robert Karasek’s “Demand/Control/Support Model”. I got to know Ulf von Euler in the early 50s, when he was my teacher of physiology. Jointly with clinical physiologist Gunnar Ström and endocrinologist Carl Gemzell, we were able to show that every-day stimuli like viewing emotionally arousing movies for one hour had a significant effect in a broad range of hormones in human subjects. Microbiologist René Dubos was the opening speaker of our fourth Symposium, addressing “Man adapting to working conditions”, exploring the impact of environmental and social factors on the welfare of humans. I first met him in the context of the UN Conference on the Human Environment, held in Stockholm in 1972. He is the person who coined the phrase “Think globally, act locally.” My own contribution (together with Gösta Carlestam) was about the stress of urbanization and life in mega-cities. In the late 60s, I was visited and interviewed by futurist Alvin Toffler, who subsequently included the increasing occupational stress burden in his 1970 best seller, “Future Shock”.
PJR: I suspect that these WHO symposia, your other publications, and the conferences and studies you did with ILO, UNICEF, UNESCO and other agencies must have stimulated considerable interest in job stress in Europe.
LL: Yes, but somewhat later. Within the European Union (EU), the first initiative came in 1993 during the Belgian Presidency, from the Belgian Minister of Labor, Ms. Miet Smet. She invited all European stakeholders to an EU Conference and asked me to be one of the keynote speakers. The deliberations made clear that there was a significant and increasing awareness of the relevance of work-related stress to workers´ health and well-being, the productivity and profitability of enterprises and the well-being of societies. One year later, Dutch psychologist Michiel Kompier and I were invited to write a book about “Stress at Work in small and medium-sized companies”, and in 1996, in collaboration with Danish economist Per Lunde-Jensen, another book on the business case for action against work-related stress. In the meantime, EU asked its Advisory Committee on Safety, Hygiene and Health Protection at Work to analyze what could and should be done to counteract work-related stress in the EU Member States. As a result, I was invited (together with my wife Inger) to prepare an EU “Guidance on Work-Related Stress – Spice of Life, or Kiss of Death?” It was published in 2000, in English, French, German, Italian and Spanish. In 2001, the European Office of the World Health Organization concluded “mental health problems and stress-related disorders are the biggest overall cause of early death in Europe.” And based on the Guidance, the European Social Partners on the Labor Market signed a Framework Agreement on Work-Related Stress in 2004 designed to improve working conditions for hundreds of millions of employees in the EU Member States.
PJR: I suspect there will be an emphasis on depression, since this is the most common debilitating mental disease. WHO predicts that by 2020, depression will be the second leading cause of disability throughout the world, trailing only coronary heart disease, to which it also contributes.
LL: In 2008, an EU and WHO-sponsored High-Level Conference adopted a European Pact for Mental Health and Wellbeing, stating, inter alia that “mental disorders are on the rise in the EU. Today, almost 50 million citizens (about 11 per cent of the population) are estimated to experience mental disorders. Depression is already the most prevalent health problem in many EU Member States.” It was further recognized that “mental health is a human right. It enables citizens to enjoy wellbeing, quality of life and health. It promotes learning, working, and participation in society (and is also) a key resource for the success of the EU as a knowledge-based society and economy.” A call for specific and coordinated actions was formulated in these five priority areas:
- Prevention of depression and suicide
- Mental health in youth and education
- Mental health in workplace settings
- Mental health in older people
- Combating stigma and social exclusion
And there are numerous efforts to implement these recommendations. The European Commission has recently started implementing the European Pact for Mental Health in a series of Conferences, most of which I had the pleasure to participate in: They include promotion of mental health and wellbeing of children and adolescents (Stockholm, 2009); Prevention of suicide and depression (Budapest, 2009); Older people’s mental health and wellbeing (Madrid, 2010); Promoting social inclusion and combating stigma (Lisbon, 2010); and Promoting mental health and wellbeing in workplaces (Berlin, 2011). In 2011, the Council of the European Union similarly recognized that “the determinants of mental health and wellbeing, such as social exclusion, poverty, unemployment, poor housing, and bad working conditions, problems in education, child abuse, neglect and maltreatment, gender inequality as well as risk factors such as alcohol and drug abuse are multifactorial and can often be found outside health systems, and that therefore improving mental health and wellbeing in the population requires innovative partnerships between the health sector and other sectors, such as social affairs, housing, employment, and education.” A basis for such a partnership is found in the EU Treaty of Lisbon, according to which “a high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities.”
A related way to systematize promotion of health and well-being has been proposed by Professor Sir Michael Marmot, (U.K.) who advocates “giving every child the best start in life; enabling all children, young people and adults to maximize their capabilities and have control over their lives; creating fair employment and good work for all; ensuring a healthy standard of living for all; creating and developing sustainable places and communities; and strengthening the role and impact of ill-health prevention.” He has promoted and implemented these activities with the assistance of his national government, the European Union and the World Health Organization, which culminated in last year’s Rio Political Declaration. And another mutual friend from the U.K., Professor Cary Cooper, succeeded in convincing the country´s former Labour government to commission a major research program on “Mental Capital and Wellbeing”. Its final 2008 report provides a remarkable menu of social action to improve well-being and prevent ill-health on a national level. Thus, there is no shortage of conferences, declarations, recommendations and even guidelines as to what needs to be done and how to achieve these goals. But, as an old Chinese proverb reads, “words do not cook rice.” There is a very considerable gap between what we know, and what we implement – the science-policy gap!
PJR: Getting back to job stress, we already have the rudiments to measure its degree and identify its causes in Karasek and Theorell’s “Demand/Control Support” and Siegrist’s Effort/Reward models, both of which were featured at our Annual Montrex Congresses. Are either of these or other approaches being utilized to reduce stress in the workplace and other settings?
LL:There are a wealth of research findings, most of which are based on one of three major theoretical models. The Demand-Control-Support Model combines three dimensions: “demands” in various social settings (should be optimal, instead of maximal, or minimal). “Control” i.e. the opportunities to manage one’s personal living and working conditions (should not be too restricted). “Support”, i.e. one´s access to social capital (should also not be too restricted). Optimal demands combined with high control and high support spell favorable and probably salutogenic living and working conditions. The Effort-Reward-Imbalance Model is based on the “effort” we invest in life and work. In an understaffed or badly organized workplace, effort is likely to be high, but this also occurs if we get over-involved. If a high effort is not rewarded (in terms of salary, praise, tenure and/or promotion), stress is likely to be excessive. If stress remains sustained with insufficient opportunities for “recharging our batteries”, the risk for dysfunction and eventually structural damage to organs and organ systems increases, as demonstrated by another of my successors at the Stress Research Institute, Professor Torbjörn Åkerstedt.
There is no doubt whatsoever that poverty kills. But so does social inequality. All major components of these three models can be modified and improved through both political and individual action, from the cradle to the grave. According to UNICEF, the true measure of a nation’s standing is how well it attends to its children – their health and safety, their material security, their education and socialization, and their sense of being loved, valued and included in the families and societies into which they were born. During working age, we ought to have a meaningful and gainful employment, referred to by ILO as “Decent Work”. And towards the end of our life cycle, we should reach retirement age with preserved health, be allowed and encouraged to choose freely between continued but adjusted gainful employment and meaningful leisure, and to continued participation and inclusion in our societies, and, of course, have access to adequate care.
PJR: We both owe a great debt of gratitude to Hans Selye, as do all who are interested in the health effects of stress. However, despite several very popular books in which he attempted to extrapolate his theories based on studies in rats to humans, it is important to emphasize that he never actually examined or treated a patient. Others also tried to demonstrate how Selye’s theories applied to people, although, as you pointed out previously, the acute and life threatening stressors his experimental animals were exposed to are quite different from the subtle threats most of us are subjected to on a daily basis. He often reminded me that theories need not be correct, only facts need to. Some theories are meritorious for their heuristic value because they encourage others to discover new facts that lead to better theories. In many respects, this applied to Selye. There is little doubt that his findings in animals were accurate, as others have confirmed them. However, it was a different story for humans. He referred many patients to me who believed their symptoms were stress related based on his books or their physician’s diagnosis. It was often difficult to convince them they were not in danger of developing the terminal “Stage of Exhaustion” of the General Adaptation Syndrome, and in a few cases, there was a non-stress related organic basis for their complaints.
On the other hand, Selye was a very stimulating and inspiring influence and encouraged others to develop their own facts and theories, even if they were icongruent with his own. I believe you first met him in 1965, when he delivered a lecture to your fledgling Stress Research group on “Pluricausal Diseases”. He encouraged the publication of an English version of your book Stress: Sources, Management and Prevention and the following year wrote the Foreword to this. He also vigorously endorsed your insistence on the need for an integrated, interdisciplinary, intersectoral approach to stress research. He similarly supported Aaron Antonovsky’s salutogenic paradigm in humans, which was quite different than Selye’s focus on pathologic changes in organs. In regard to Hans Selye, you once wrote:
Dr. Selye often pointed out that the Bible’s formulation “love thy neighbor as thyself” was to ask too much. Instead he proposed his own formulation “earn they neighbor’s love”. He referred to this as altruistic egoism. He definitely did earn my love through his never failing kindness, support, profound knowledge and willingness to help. He was a macrobiologist, who often pointed out that there were so many producers of bricks, but so few architects. The castle he constructed may need some modification and reconstruction but is still an everlasting contribution to science and humanity.
That was 20 years ago at one of our Montreux Congresses on Stress in Switzerland, and I wondered if your views had changed since then.
LL: I vividly remember Selye referring to most researchers and scientists as producers of “separate bricks”. He emphasized that it was not enough to have all the necessary bricks to build a cathedral. The bricks must be placed in complex patterns relative to each other. “Otherwise, you end up with a heap of bricks.” But, as you indicated, Selye’s General Adaptation Syndrome or his stress research in animals cannot explain the concepts of salutogenesis and “Sense of Coherence”. Real life is more complicated for humans. We see this in health responses to natural and man-made disasters. The former would include avalanches, droughts, earthquakes, floods, hurricanes, typhoons, mudslides, tsunamis, and volcanic eruptions. The latter comprise accidents in communities and work sites, nuclear leaks and meltdowns, oil spills from ships and wells, terrorist attacks, transportation accidents, war and civil destruction acts, unemployment, homelessness, poverty or nuclear waste disposal. For example, as co-chair of a WHO expert mission to Chernobyl in 1990, I had the opportunity to study some of the effects on public health and wellbeing of the large-scale nuclear accident occurring there four years earlier. According to our analysis, the effects were mediated through seven types of mechanisms that can be summarized as follows:
- Socio-psychological (the population’s perception of risk, partly based on the information – and disinformation – available)
- Socio-cultural (evacuation and resulting displacement of populations, disruption of families, neighborhoods and communities)
- Psychophysiological stress reactions (psycho-neuro-endocrine over-arousal and subsequent exhaustion, with mental, cardiovascular, musculoskeletal and other functional and/or structural pathology)
- Lifestyle changes (with regard to food, tobacco, alcohol, illicit drugs, anti-social and/or self-destructive behaviors)
- Medico-social (with regard to population illness behavior and care-givers´ diagnostic and therapeutic behavior – attribution)
- Socioeconomic (through the resulting unemployment, homelessness and poverty)
- Radio-pathological and toxicological (exposure to radiation and radioactive isotopes, toxic materials)
It is not uncommon for authorities to consider only one or a few of such pathogenic pathways and neglect the remaining, equally or more important ones. The complexity of challenges in real life necessitates a holistic, systems approach, difficult to achieve in post-industrial countries traditionally based on vertical “silo” approaches. Public health has been defined as “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, public and private organizations, communities and individuals.” In social systems characterized by the “verticalitis” just mentioned, this is easier said than done.
Getting back to Selye, towards the second half of his career he became almost a homo universalis, with his M.D., Ph.D. and D.Sci. degrees and his enormous knowledge and integrative abilities. As you have detailed elsewhere, he worked 12 hours a day, seven days a week. He produced some 1,300 scientific papers, scores of books and countless lectures. His response to my question as to how on earth he could manage such enormous productivity, he answered: “When is a hunting dog happy? — When he is allowed to hunt.” That may be true, but when and how his “prey” is utilized and appreciated may be more important for humans. Many discoveries and much knowledge are never applied, or are applied with a very considerable delay due to concerns about costs. This is starting to change. The British Government very recently asked the London School of Economics to calculate the cost-benefit ratio for a number of investments and outcomes based on available evidence. The results reveal that for every GBP (British Pound Sterling) invested, the total returns are as follows:
Workplace health promotion GBP = 9.7
Screening of alcohol abuse GBP = 11.8
School-based interventions to reduce bullying GBP = 14.4
Suicide prevention training course to all General Practitioners GBP =44.0
Prevention of conduct disorders through social and emotional learning programs GBP =83.7.
Even half of these saving opportunities should impress the Ministers of Finance and decision makers of most countries! Our major task now is to communicate this information to these individuals and to convince them to act accordingly. By evaluating the results and learning from experience, the decision making loop will become self-corrective. As noted previously, great strides in narrowing this wide “science-policy gap” are being implemented in the UK by Professors Michael Marmot and Cary Cooper, and by economists and elected officials in France and other EU countries. While this trend is encouraging, more research is indeed needed because the social determinants of our health are changing so rapidly. Nevertheless this must be complemented by implementation of what is, indeed, already known from existing evidence!